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Based on review of facility record and staff interview, the facility failed to provide emergency care and services, as required, to 1 of 20 sampled patients (#1) who presented to the hospital with a request for such care, as evidenced by: patient #1 was brought to the hospital's Emergency Respond Unit by a police officer under the Baker Act on 10/13/10; the patient was sent to another hospital without any documented record of the patient presenting, or being identified in the facility's emergency care Control / Central Log and without receiving a medical screening exam (MSE) to determine if an emergent condition existed, nor was an appropriate transfer with accompanying medical information performed.

The findings include:

Review of the facility's documentation shows patient #1 was brought to the lobby of the Pavilion (hospital psychiatric facility) by a police officer on 10/13/10 at 4:00 AM. The police officer reportedly told facility staff the patient was being Baker Acted and had felony charges pending; the facility's documentation indicates the psychiatric unit nursing supervisor reportedly instructed staff to call another hospital to determine if a bed was available there and not to triage/assess the patient. The patient was never registered, did not receive a MSE and did not receive an appropriate transfer to another hospital.

During an interview with the Director of Behavioral Health on 11/8/10 at 3:45 PM, she stated that she doesn't know what happened or what the staff were thinking. She stated that all staff are trained in EMTALA regulations and hospital policy and procedure and, the nursing supervisor who was on duty at the time of this event has been employed with the facility for several years. She states that the facility was full and had no beds available at that time, but that did not negate the fact that staff were still obligated to register the patient, provide a MSE (medical screening exam) and initiate the transfer appropriately. She stated that when she spoke with the nursing supervisor, the nursing supervisor could not give a reason why she failed to follow the appropriate procedures.

During an interview with the RM (risk manager) on 11/8/10 at 4:00 PM, he stated that the hospital has developed a new on-line training program for EMTALA regulations and procedures that all staff will be required to complete and that new PI (performance improvement) measures have been implemented for the Pavilion to monitor compliance with EMTALA regulations and procedures.

See deficiencies cited at tags A-2403, A2405, A2406, A2407 and A2409.

Based on review of facility record and staff interview, the facility failed to ensure that a medical record was created and maintained for 1 of 20 sampled patients (#1) who presented to the facility for emergency care.

The findings include:

Review of the facility's documentation shows that patient #1 was brought to the lobby of the Pavilion (hospital psychiatric facility) by a police officer on 10/13/10 at 4:00 AM. The police officer reportedly told facility staff the patient was being Baker Acted and had felony charges pending; the psychiatric unit nursing supervisor reportedly instructed staff to call another hospital to determine if a bed was available there and not to triage/assess the patient. The patient did not receive a Medical Screening Exam (MSE) and no medical record was created for the patient to substantiate appropriate provision of care, to determine if the patient had an emergent condition, needed treatment, stabilization and necessary transfer to another facility with capability or capacity that University Hospital and Medical Center does not have prior to the transfer of the patient to another hospital.

During an interview with the Director of Behavioral Health on 11/8/10 at 3:45 PM, she stated that she doesn't know what happened or what the staff were thinking. She stated that all staff are trained in EMTALA regulations and hospital policy and procedure and, the nursing supervisor who was on duty at the time of this event, has been employed with the facility for several years. She states that the facility was full and had no beds available at that time but that did not negate the fact that staff were still obligated to register the patient. She stated, the nursing supervisor could not give a reason why she failed to follow the appropriate procedures.

During an interview with the RM (risk manager) on 11/8/10 at 4:00 PM, he stated that the hospital has developed a new on-line training program for EMTALA regulations and procedures that all staff will be required to complete and that new PI (performance improvement) measures have been implemented for the Pavilion to monitor compliance with EMTALA regulations and procedures.

Based on review of facility record and staff interview, the facility failed to ensure the emergency care Control / Central Log recorded and identified 1 of 20 sampled patients (#1), who presented to the facility for emergency care as evidenced by: patient #1 was brought to the hospital's Respond Unit by a police officer under the Baker Act on 10/13/10; the patient was sent to another hospital without being registered and listed/identified in the facility's emergency care Central Log/Record.

The findings include:

Review of the facility's documentation shows that patient #1 was brought to the lobby of the Pavilion (hospital psychiatric facility) by a police officer on 10/13/10 at 4:00 AM. The police officer reportedly told facility staff the patient was being Baker Acted and had felony charges pending; the psychiatric unit nursing supervisor reportedly instructed staff to call another hospital to determine if a bed was available there and not to triage/assess the patient. The patient was never registered or identified in the facility's emergency care Control Central Log.

During an interview with the Director of Behavioral Health on 11/8/10 at 3:45 PM, she stated that she doesn't know what happened or what the staff were thinking. She stated that all staff are trained in EMTALA regulations and hospital policy and procedure and, the nursing supervisor who was on duty at the time of this event, has been employed with the facility for several years.

During an interview with the RM (risk manager) on 11/8/10 at 4:00 PM, he stated that the hospital has developed a new on-line training program for EMTALA regulations and procedures that all staff will be required to complete and that new PI (performance improvement) measures have been implemented for the Pavilion to monitor compliance with EMTALA regulations and procedures.

Based on review of facility record and staff interviews, the facility failed to provide a MSE to determine if an emergency medical condition existed for 1 of 20 sampled patients (#1) who presented to a dedicated emergency department of the hospital.

The findings include:

Review of the facility's documentation shows that patient #1 was brought to the lobby of the Pavilion (hospital psychiatric facility) by the hospital's Respond Unit by a police officer on 10/13/10 at 4:00 AM. The police officer reportedly told facility staff that the patient was being Baker Acted and had felony charges pending; the psychiatric unit nursing supervisor reportedly, per the facility's documentation, instructed staff to call another hospital to determine if a bed was available there and not to triage/assess the patient. The patient did not receive a Medical Screening Exam as required to determine if an emergent condition existed.

During an interview with the Director of Behavioral Health on 11/8/10 at 3:45 PM, she stated that she doesn't know what happened or what the staff were thinking. She stated that all staff are trained in EMTALA regulations and hospital policy and procedure and, the nursing supervisor who was on duty at the time of this event, has been employed with the facility for several years. She states that the facility was full and had no beds available at that time but that did not negate the fact that staff were still obligated to register the patient, provide a MSE (medical screening examination).

During an interview with the RM (risk manager) on 11/8/10 at 4:00 PM, he stated that the hospital has developed a new on-line training program for EMTALA regulations and procedures that all staff will be required to complete and that new PI (performance improvement) measures have been implemented for the Pavilion to monitor compliance with EMTALA regulations and procedures.

Based on review of medical records, policy and procedure and staff interviews the facility failed to ensure that their policy was followed regarding providing stabilizing treatment to an individual that was within the capability and capacity of the hospital for 1 of 20 sampled patients (#1).

Findings include:

Review of the facility's policy titled, "Florida Medical Screening Examination and Stabilization Policy" indicated in part, ". . . the individual will be provided necessary stabilizing treatment, within the capacity and capability of the facility."

Documentation on Patient #1's medical record shows that the patient was brought to the lobby of the Pavilion (hospital psychiatric facility) by the hospital's Respond Unit by a police officer on 10/13/10 at 4:00 AM. The police officer reportedly told facility staff that the patient was being Baker Acted and had felony charges pending; the psychiatric unit nursing supervisor reportedly, per the facility's documentation, instructed staff to call another hospital to determine if a bed was available there and not to triage/assess the patient. There is no evidence found or provided to support the patient received stabilizing treatment, or that stabilization, prior to transfer was not within the capability or capacity of University Hospital and Medical Center. No supportive evidence was found indicating the emergency medical condition that caused patient #1 to seek emergency care was treated or stabilized prior to transferring the patient.

During an interview with the Director of Behavioral Health on 11/8/10 at 3:45 PM, she stated that she doesn't know what happened or what the staff were thinking. She stated that all staff are trained in EMTALA regulations and hospital policy and procedure and, the nursing supervisor who was on duty at the time of this event, has been employed with the facility for several years.

During an interview with the RM (risk manager) on 11/8/10 at 4:00 PM, he stated that the hospital has developed a new on-line training program for EMTALA regulations and procedures that all staff will be required to complete and that new PI (performance improvement) measures have been implemented for the Pavilion to monitor compliance with EMTALA regulations and procedures.

Based on review of facility record and staff interviews, the facility failed to initiate and provide an appropriate transfer for 1 of 20 sampled patients (#1) who was presented for care to the dedicated emergency department of the hospital.

The findings include:


Review of the facility's documentation shows that patient #1 was brought to the lobby of the Pavilion (hospital psychiatric facility) by a police officer on 10/13/10 at 4:00 AM. The police officer reportedly told facility staff that the patient was being Baker Acted on 10/13/2010, and had felony charges pending; the psychiatric unit nursing supervisor reportedly instructed staff to call another hospital to determine if a bed was available there and not to triage/assess the patient. No supportive evidence was found to suggest that University Hospital and Medical Center: (1) contacted the receiving facility; (2) the risks and benefits of the transfer was explained to the patient; and (3) a copy of a completed and accurate medical record for patient #1 was sent to the receiving facility.

During an interview with the Director of Behavioral Health on 11/8/10 at 3:45 PM, she stated that she doesn't know what happened or what the staff were thinking. She stated that all staff are trained in EMTALA regulations and hospital policy and procedure and, the nursing supervisor who was on duty at the time of this event, has been employed with the facility for several years. She states that the facility was full and had no beds available at that time but that did not negate the fact that staff were still obligated to initiate an appropriate transfer to include contacting the receiving facility; explaining the risks and benefit of the transfer to the patient, and sending copies of the patient's medical record to the receiving facility.

During an interview with the RM (risk manager) on 11/8/10 at 4:00 PM, he stated that the hospital has developed a new on-line training program for EMTALA regulations and procedures that all staff will be required to complete and that new PI (performance improvement) measures have been implemented for the Pavilion to monitor compliance with EMTALA regulations and procedures.