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Based on medical record review, policy review and staff interviews it was determined the facility was not in compliance with 42 CFR 489.24.

The facility failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for one (#6) of 21 sampled patients presenting to the emergency department that was within the facility's capabilities. (Refer to Tag - A2406).

The facility failed to ensure a proper transfer with all information was completed for two (#10, #12) of 21 sampled patients. (Refer to Tag- A2409).

The facility failed to ensure required signage was conspicuously posted in the Obstetrical Emergency Department. (Refer to Tag - A2402)

Based on observation and staff interview it was determined the facility failed to ensure required signage was posted in the area designated as the Obstetrical Emergency Department.

Findings included:

A tour of the Obstetrical Emergency Department (OBED) was conducted on 7/2/18 at 10:00 a.m., accompanied by the Nurse Manager of the Labor and Delivery Unit. Observations conducted at the time of the tour revealed there were no signs, posters, or other written communication posted anywhere in sight at the entrance or waiting area to advise emergency patients or women in labor of their rights, or whether the facility participated in the medicaid program.

The finding was confirmed by the Risk Manager in an interview conducted on 7/3/18 at 3:45 p.m.

Based on review of medical records, policy and procedure review and interview the facility failed to ensure the medical record contained a description of the examination treatment and or both that was refused by the individual (#6); and the facility failed to take all reasonable steps to secure the individual's written informed refusal for one (#6) of twenty-one sampled patients.
Findings included:

The facility's policy titled "Medical Screening, Stabilization, and Transfer (RE: EMTALA FLORIDA ACCESS TO EMERGENCY SERVICES AND CARE ACT COMPLIANCE)" Policy #120.91A date implemented:6/97..date revised 1/17 was reviewed. The policy stated in part, "Refusal of Evaluation/stabilizing treatment/transfer: if a patient refuses to consent to a medical screening examination, treatment, or transfer, the following steps should be taken to secure a written informed refusal of such examination, treatment and/or transfer from the patient or a person acting on the patient's behalf: 1. The physician treating the patient should give an explanation of the increased medical risks that may be reasonably expected from not being examined, treated or transferred, and the medical benefits reasonably expected from the provision of appropriate treatment and/or transfer. 2. The refusal of Evaluation/Stabilizing Treatment/Transfer form should be completed and, if possible, signed by the patient or person acting on the patient's behalf, dated and witnessed, and placed in the patient's record. 3. If the patient or person acting on the patient's behalf refuses the consent, but will not sign a refusal or consent form, the refusal should be clearly documented in the electronic medical record."


The Face Sheet indicated Patient #6 arrived at the Obstetrical Emergency Department (OBED) on 6/13/18 at 2:15 a.m., and was discharged from OBED on 6/13/18 at 3:13 a.m. The Face Sheet indicated the discharge disposition was Against Medical Advice, indicating Patient #6 had refused the medical recommendations of the examining provider and left the facility without receiving recommended care after being fully informed of the potential risks of not following the medical recommendations.

The Nursing Documentation dated 6/13/18 at 3:20 a.m., and signed by the qualified RN indicated Patient #6 came to the OBED on the instructions of her obstetrician because her water broke. Patient #6 indicated this was not the facility where she wanted to deliver her baby. The documentation included the nurse informed the patient she had the right to go where she wanted. The patient and her husband chose to leave.

The review of the entire OBED record failed to reveal any evidence of the assessment of either the mother or the fetus. There was no evidence vital signs were taken. The mother's gestational age was not documented. There was no evidence the RN contacted the patient's obstetrician or made any attempt to contact the hospitalist obstetrician. There was no evidence Patient #6 was offered or recommended to have a medical screening examination prior to her departure. There was no evidence Patient #6 was advised of the potential risks presented to herself or her baby by leaving the facility without being evaluated.

The Risk Manager confirmed the findings in an interview conducted on 7/3/18 at 3:45 p.m.

Based on review of medical records, staff interview and review of facility policy and procedures it was determined the facility failed to ensure a physician documented the medical benefits outweighed the risks of a transfer to another medical facility and the medical record contained a summary of risks and benefits upon which it was based for two
(#10, #21) of twenty-one patients sampled.

Findings included:

Review of the facility policy, "Transferring and Transporting Patient To and From Other Institutions", states the nurse in charge or case manager will facilitate the following to affect the transfer of any patient being transferred out of Transfer Center to another acute care facility: obtain consent of the patient or the patient's representative prior to transfer; if the transfer is pursuant to physician order, the physician must sign the physician certification form stating that the medical benefits expected from provision of care at another facility outweigh the risk of transfer and include a summary of the physician's assessment of such risks and benefits.

1. Review of the medical record for patient #10 revealed the patient arrived to the facility on 5/01/2018 at 2:46 am. Review of the physician's medical screening examination at 3:18 am determined the patient had a psychiatric history, substance abuse history, reported feeling depressed and admitted to suicidal ideation. Documentation revealed at 4:52 a.m., the patient was medically cleared. Physician documentation stated the patient requested to be transferred to a specific psychiatric facility.

Review of the medical record revealed the physician discharged the patient at 4:58 p.m., with referral to psych. Nursing documentation revealed communication with the specific psychiatric facility was conducted. Nursing documentation stated at 6:07 a.m., the psychiatric facility accepted the patient, report was provided and at 6:53 am the patient was transported via emergency medical services.

Review of the record revealed no evidence physician certification was completed and included a summary of the risks and benefits or the patient's signed acknowledgement of the risks and benefits. Interview with the Director of Patient Safety/Risk Management on 7/02/2018 at approximately 2:10 p.m., confirmed the above findings.

2. Review of the medical record for patient #21 revealed the patient arrived to the facility on 6/29/2018 at 3:34 am. Review of the physician's medical screening examination at 3:48 am determined the patient had a history of anxiety, depression, substance abuse and reported suicidal and homicidal ideation's. The patient reported auditory hallucinations. Documentation revealed at 6:21 am the patient was re-examined, the physician medically cleared him at 6:22 a.m, for psychiatric evaluation, completed a Baker Act 52 form and discharged the patient at 6:23 am.

Nursing documentation revealed the patient was accepted at a psychiatric facility and transported by emergency medical services at 7:55 a.m. Review of the record revealed no evidence physician certification was completed and included a summary of the risks and benefits or the patient's signed acknowledgement of the risks and benefits. Interview with the Director of Patient Safety/Risk Management on 7/03/2018 at approximately 2:30 p.m., confirmed the above findings.