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Based on interview, and record review, it was determined the facility is not in compliance with the medical screening examination requirement to determine if an emergent medical condition exist, the facility failed to provide the necessary stabilizing treatment and failed to ensure an appropriate transfer for 2 out of 22 Sample Patients (SP), (SP#21, SP#22).

The facility failed to be in compliance with the Emergency Medical Treatment and Labor Act requirements at 489.24.

1. Refer to A-2406.

2. Refer to A-2407.

3. Refer to A-2409.

Based on medical record review, policy and procedure review and interview, the facility failed to document and maintain medical and other records related to the individuals transferred to and from the hospital for a period of 5 years from the date of the transfer in 2 out of 22 Sampled Patients (SP) (SP#21, and SP#22).

The findings include:

Information contained in an electronic mail (e-mail) from the local fire and rescue revealed that on May 12, 2012 at approximately 2020 (8:20 PM), Rescue was called out to a motor vehicular accident (MVA). Two (2) pediatric Basic Life Support (BLS) patients were sent to the hospital. A four (4) year old (SP#21) and a six (6) year old (SP#22), both siblings and their mother were transported.

The Emergency Department Director (ED Dir.) was asked by the surveyor about her knowledge of the incident on May 12, 2012 and the ED Dir. stated on July 9, 2012 from 10:43 A.M. to 12:15 P.M., the patients were brought together in one (1) rescue truck by the Paramedic, Firefighter F#1 and Firefighter F#2. The ED Dir. stated, "Fire Rescue brought the patients in a stretcher, entered the ED, met by the ED Pediatrician and Pediatric Nurse (PN)#1. The patients were not transferred to the beds, only stayed within the hallway. The ED Pediatrician told the Fire Rescue personnel, the patient (6 year old) (SP #22) is a Trauma patient and should be transferred to Hosp.#2. The ED Pediatrician did a quick assessment while the patient was on the stretcher but did not document. The ED Pediatrician stated to the Ped. ED Med. Dir. the patient had a rigid abdomen and PN#1 told me this is what the ED Pediatrician said on that night." The ED Dir. further added, she spoke to PN#1 who told her the patients were brought by Fire Rescue, met by the ED Pediatrician who looked at the first baby and then the second (2nd) baby (6 year old). The 2nd baby had a "rigid abdomen" and the ED Pediatrician told Fire Rescue the patient needs to be brought to Hosp.#2. PN#1 told the ED Dir. Fire Rescue turned around and took the patients to Hosp.#2.

Interview of the Ped. ED Med. Dir. conducted on July 10, 2012 from 11:26 A.M. to 11:50 A.M. revealed, according to the ED Pediatrician "2 patients came together in 1 Fire Rescue truck, 1 in each stretcher. 1 patient had blood on the face and 1 patient did not look right". The ED Pediatrician checked the patient and noted the lap-band sign or mark on the abdomen, the abdomen was tender to touch and told Fire Rescue to go straight to Hosp.#2 because of the presence of an abdominal injury, the patient needed a surgical evaluation which is not available in Hosp. #1. The patients were examined in the hallway by the ED Pediatrician. The ED Pediatrician stated to the Ped. ED Med. Dir. "I do not know what happened, why I did not document. I wanted the patients transferred right away because of the injuries." The Ped. ED Med. Dir. confirmed on July 10, 2012 at 11:45 A.M. that there was no documentation done by the ED Pediatrician on the 2 patients.

Pediatric Nurse (PN)#1 stated during an interview conducted on July 11, 2012 from 7:35 A.M. to 7:58 A.M. in the presence of the ED Unit Leader (ED U.L.) revealed, Fire Rescue came with the kids. They were met by the ED Pediatrician in front of Room 2. He examined them, looked them over, palpated, it was relatively quick; time-wise, I can't tell. One of the children had bruising on the face, injuries and the other child had seat belt marks. The ED Pediatrician said, they were trauma patients and they need to go to a trauma center, it's a belly that needed a surgeon". PN#1 was asked if vital signs were taken and the answer was, "No vital signs were taken."

The ED Dir. confirmed on July 9, 2012 at 12:00 P.M. by stating, "The Pediatrician and the Pediatric Nurse did not document anything at all. No medical records for these patients." The facility failed to ensure that medical records and other records related to sampled Patients #21 and #22 were maintained on May 12, 2012 when these patients presented on the hospital's grounds.

Based on the review of Emergency room Logs, policy and procedures, record review and interview(s), the facility failed to maintain a central log on each individual who comes to the Emergency Department in 2 out of 22 Sampled Patients (SP) (SP#21, and SP#22).


The findings include:

The hospital's policy titled, " EMTALA(Emergency Medical Treatment and Labor Act) -Florida Central Log Policy " Review/Revised Date .... 6/2012 was reviewed. The policy documented in part, "Policy: The hospital will maintain Central Log information on each individual who comes to the hospital campus, requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination (MSE) could be performed, whether he or she was refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged."

The Emergency Room Register Log used by the Flow Charge Nurse showed documentation that on May 12, 2012 at 2050(8:50PM) information was received from R-58 about a 4 year old with right cheek pain and on May 12, 2012 at 2051 (8:51 PM), information was received about a 6 year old with nosebleed and abdominal pain.

The Emergency Department Director (ED Dir.) stated on an interview conducted on July 9, 2012 at 10:43 A.M. to 12:15 P.M., whenever a patient is brought to the ED, a piece of paper is stamped by either the Fire Rescue or Ambulance personnel and then given to the Unit Secretary (U.S.).
A telephone interview of the Unit Secretary who worked on the 7 P.M. to 7 A.M. shift on May 12, 2012 was conducted on July 9, 2012 at 4:51 P.M. in the presence of the Emergency Department Director and the Director of Risk Management. She stated, "I do not remember these patients that night. The Nurse Director talked about the incident that there were 2 patients who were not accepted or placed in the computer and then were transferred to another hospital."

The Electronic Central Log for Both Emergency Services and Labor & Delivery Departments for May 12, 2012 failed to show documentation of the names of SP#21 and SP#22.

The above findings were confirmed with the ED Dir. on July 9, 2012 at 12:15 P.M., there was failure by the facility to document and maintain a central log for each individual who comes to the ED.

Based on review of the hospital's Emergency Department (ED) Reportable Issue form, policy and procedures and interview(s), the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability and capacity of the hospital's emergency department to determine if an emergency medical condition existed for 2 out of 22 Sampled Patients (SP) (SP#21, and SP#22) when these Individuals presented to the hospital on May 12, 2012.

The findings include:

A review of the hospital's policy titled, " EMTALA-Florida Medical Screening Examination and Stabilizing Policy" Review and revised date 6/2012 was reviewed. The policy specified in part, "Procedure: . . 2. When an MSE (medical screening examination) is required: A hospital must provide an appropriate MSE with the capability of the hospital's emergency department, including ancillary services routinely available to the DED (Dedicated Emergency Department), to determine whether or not an EMC (Emergency Medical Condition) exists: ...(ii) an individual who has such a request made on his or her behalf; (iii) an individual whom a prudent layperson observer would conclude from the individual's appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC .. A. ii. . . The MSE of the individual must be documented."

SP #21's medical record from the receiving hospital was reviewed. Review of the ED/Triage Assessment-Text, indicated the patient arrived via ambulance on May 12, 2012, and the patient was triaged and assessed by the ED nurse at 9:35 P.M. The " ED Note-Physician ...Final Report " dated May 12, 2012 indicated in part, " Motor vehicle crash-major. . . History of present illness: 4 year old with a history of renal surgery secondary to uretheral reflux (abnormal movement of urine from the bladder into the ureters or kidneys) c/o (complain/of) abdominal pain and right cheek pain after being involved in a MVA (motor vehicle accident). . . Skin symptoms: Bruising, abrasions, right cheek ecchymosis and edema with pain ...Gastrointestinal symptoms: Abdominal pain, moderate, right lower quadrant, left lower quadrant, constant ...Physical examination: Skin: Wound(s): lower abdomen and abrasion ...Head ...right cheek, ecchymosis (passage of blood from a ruptured blood vessel into subcutaneous tissue- purple discoloration) and edema... .Gastrointestinal: abdominal distension (swelling). Tenderness: moderate, right lower quadrant, and left lower quadrant ... Trauma: right lower quadrant, left lower quadrant abrasions and ecchymosis. Signs: positive Seatbelt sign ...medical decision making: differential diagnosis: Head injury, contusion, neck injury, internal hemorrhage, abrasion ... Impression and plan: Diagnosis: Trunk abrasion ... Contusion (bruise) to the face. Admit for further evaluation and treatment. Ped SurgH&P (History and Physical): Basic information: Admit information: Admit to surgery; S/P (status/post) trauma ... review of systems: Eye: right eye swollen shut with bruising.. .gastrointestinal: Abdominal pain: lower quadrant, pt (patient) with moderate to severe abdominal pain and bruising overlying her suprapubic areas (Urinary and Uterus) where her seat belt was."

SP' s #22 medical record from the receiving hospital was reviewed. A review of the ED/Triage Assessment -Text, revealed that the patient arrived via ambulance on May 12, 2012. The patient was triaged and assessed by the ED nurse at 9:39 P.M. The " ED Note Physician . . .Final Report " dated May 12, 2012 . . .History of Present illness: 6 y/o ... with a h/o (history /of) Choanal atresia (congenital disorder where the back of the nasal passageway is blocked), c/o abdominal pain and epistaxis (after being involved in a MVA). ENMT (Ear, nose, mouth, throat) Nose: Bleeding, swelling. . .gastrointestinal symptoms: Abdominal pain severe, right lower quadrant, left lower quadrant, constant. . .Physical examination: Ears nose, and throat:. . .Nose/nares: Bleeding, tenderness and swelling. . . Gastrointestinal: Abdominal distension, tenderness: severe, right lower quadrant and left lower quadrant. Guarding: moderate and involuntary. . . Medical Decision Making: Differential Diagnosis: head injury, fracture, closed contusion, laceration, abrasion.. Plan: Admit to inpatient unit. " The Discharge summary revealed in part, "CT (Computerized Tomography scan- specialized x-ray) of the head, which showed. . .nasal bone fracture ...CT of abdomen showed small bowel injury and edema, and ischemia (decrease in blood supply to a bodily organ or tissue). . . Transferred to PICU (pediatric intensive care unit-unit within the hospital where specializing in care critically ill children) ... surgery on May 13, 2012 for closed reduction of decompressed fracture . . . surgery on May 13, 2012 for an ischemic small intestine and perforation of the sigmoid colon (medical condition an injury of large intestine result from inadequate blood supply in which) ... exploratory laparotomy (surgical procedure that explores the abdomen) . . . ...small bowel resection ... sigmoid colon resection with .... And distal colostomy (surgical procedure where a portion of the large intestine is brought through the abdominal wall to carry stool out of the body)."
The Emergency Department Director (ED Dir.) was asked by the surveyor about her knowledge of the incident on May 12, 2012 and the ED Dir. stated on July 9, 2012 from 10:43 A.M. to 12:15 P.M. that the patients were brought together in one (1) rescue truck by the Paramedic, Firefighter #1 and Firefighter F#2. The patients were not transferred to the beds, only stayed within the hallway. The ED Pediatrician told the Fire Rescue personnel that the patient (6 year old) is a Trauma patient and should be transferred to Hosp.#2. The ED Pediatrician did a quick assessment while the patient was on the stretcher but did not document the assessment.

The hospital's ED Reportable Issue (RI) form dated May 18, 2012 revealed a Summary of the RI as follows: On 5/12/12, Fire Rescue transported 2 pediatric patients Status/Post MVA to Hospital (Hosp.) #1 as a non-trauma alert. Upon arrival, the Pediatric ER physician noted that Patient A had facial trauma (later determined to be a fractured nose) and seat belt marks with a distended abdomen. The physician told Fire Rescue that Patient A needed to be transported to Hosp.#2 as a trauma alert. Hosp.#1 is not a pediatric trauma facility. The 2 patients were not accepted in the system or evaluated by the nurse and did not receive a complete screening by the Pediatric ER physician.

Interview of the Ped. ED Med. Dir. conducted on July 10, 2012 from 11:26 A.M. to 11:50 A.M. revealed that according to the ED Pediatrician "2 patients came together in 1 Fire Rescue truck, 1 in each stretcher. One patient had blood on the face and 1 patient did not look right." The ED Pediatrician checked the patient and noted the lap-band sign or mark on the abdomen, the abdomen was tender to touch and told Fire Rescue to go straight to Hosp.#2 because of the presence of an abdominal injury, the patient needed a surgical evaluation which is not available in Hosp. #1. The patients were examined in the hallway by the ED Pediatrician. The ED Pediatrician stated to the Ped. ED Med. Dir. "I do not know what happened, why I did not document. I wanted the patients transferred right away because of the injuries." The Ped. ED Med. Dir. confirmed on July 10, 2012 at 11:45 A.M. there was no documentation done by the ED Pediatrician on the 2 patients. There is no evidence of any documentation for SP#21 and SP#22 that an appropriate MSE was performed to determine whether or not an Emergency Medical Condition (EMC) existed, when the patients presented to the ED on May 12, 2012.

Pediatric Nurse (PN) #1 stated during an interview conducted on July 11, 2012 from 7:35 A.M. to 7:58 A.M. in the presence of the ED Unit Leader (ED U.L.) revealed, Fire Rescue came with the kids. They were met by the ED Pediatrician in front of Room 2. He examined them, looked them over, palpated, it was relatively quick; time-wise, I can't tell. One of the children had bruising on the face, injuries and the other child had seat belt marks. The ED Pediatrician said that they were trauma patients and they need to go to a trauma center, it's a belly that needed a surgeon." Pediatric Nurse (PN#1) was asked if vital signs were taken and the answer was "No vital signs were taken." There was also no evidence of triage assessments provided for SP# 21 and SP #22 on May 12, 2012.
The above findings were confirmed from the Ped. ED Med. Dir. on July 10, 2012 at 11:50 A.M. there was failure by the ED Pediatrician to provide an appropriate MSE of SP#21 and SP #22 on May 12, 2012 for both patients with EMC's and failure to maintain documentation of the MSE's findings, as stated in their policy.

Based on interview, review of policy and procedure, Emergency Department's Reportable issue and medical record review, the facility failed to provide the necessary stabilizing treatment that was within the capability and capacity of the hospitals Dedicated Emergency Department (DED) for 2 out of 22 Sample Patients (SP) (SP#21, and SP#22). See tag 2406 for additional information on SP #21 and SP #22.

The findings are:


The hospital's policy titled, "EMTALA (Emergency Medical Treatment and and Labor Act) - Florida Medical Screening Examination and Stabilization Policy" documents the hospital must provide an appropriate Medical Screening Examination (MSE) to determine whether or not an an Emergency Medical Condition (EMC) exists. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment or an appropriate transfer.

The hospital's Emergency Department's Reportable Issue (RI) form dated May 18, 2012 revealed a Summary of the RI as follows: On 5/12/12, Fire Rescue transported 2 pediatric patients Status/Post MVA to Hospital (Hosp.)#1 as a non-trauma alert. The 2 patients were not recepted in the system or evaluated by the nurse and did not receive a complete screening by the Pediatric ER physician. There was no patient information entered into the Central Log.

The ED Dir. confirmed on July 9, 2012 at 12:00 P.M. by stating, " The Pediatrician and the Pediatric Nurse did not document anything at all. No medical records for these patients." There is no evidence of any documentation for SP#21 and SP#22 that any stabilizing treatment were done before the patients were taken by Fire Rescue to Hosp.#2 as of May 12, 2012.

Interview of the Pediatrics Emergency Department Medical Director. conducted on July 10, 2012 from 11:26 A.M. to 11:50 A.M. The Ped. ED Med. Dir. confirmed on July 10, 2012 at 11:45 A.M. that there was no documentation done by the ED Pediatrician on the 2 patients.

Pediatric Nurse (PN)#1 stated during an interview conducted on July 11, 2012 from 7:35 A.M. to 7:58 A.M. in the presence of the ED Unit Leader revealed that Fire Rescue came with the kids. They were met by the ED Pediatrician in front of Room 2. He examined them, looked them over, palpated, it was relatively quick; time-wise, I can't tell. One of the children had bruising on the face, injuries and the other child had seat belt marks. The ED Pediatrician said, they were trauma patients and they need to go to a trauma center, it's a belly that needed a surgeon." Pediatric Nurse PN#1 was asked if vital signs were taken and the answer was, "No vital signs were taken."

Based on a review of policy and procedures and interview, the facility failed to ensure that an appropriate transfer was provided for 2 out of 22 Sampled Patients (SP) (SP#21, and SP#22).

The findings include:

The hospital's policy and procedure titled, "Transfer of Patients to Other Facilities or Agencies" documents any transfer of an individual with an Emergency Medical Condition (EMC) must be initiated by the written request from the patient or the legally responsible person acting on the patient's behalf for such transfer or by a physician order with the appropriate physician certification. It is further documented (a) the transferring hospital must, within its capability, provide treatment to minimize the risks to the health of the individual, (b) the receiving hospital must have available space and qualified personnel for the treatment of the individual and must have agreed to accept the transfer and (c) the transferring hospital must send copies of available medical records related to the individual's EMC.

The ED Dir. confirmed on July 9, 2012 at 12:00 P.M. by stating, "The Pediatrician and the Pediatric Nurse did not document anything at all. No medical records for these patients." There is no evidence of any documentation for SP#21 and SP#22 on May 12, 2012 that an appropriate transfer was undertaken by Hosp. #1 as stated in the facility's policy and procedure.