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Based on review of clinical medical records, review of Emergency Activity Log, review of audio recording and audio recording transcripts, Fire Rescue report review, facility discharge summary review, review of Physician Core Privileges, policies and procedures, interview with Emergency Medical Services (EMS) staff, and physicians, the facility failed to provide stabilizing treatment as required that was within the capability of the hospital emergency department for (#1) of 20 sampled patients who presented to the Emergency Department (ED) with an identified emergency medical condition. This failure resulted in delay in treatment and resulted in potential harm including the possibility of respiratory distress, and respiratory failure for Patient #1. Refer to findings in Tag A-2407.


Based on Emergency Room medical record reviews, ED Discharge Summary review, Emergency Medical Services (EMS) report, audio recordings and phone transcripts, review of policy and procedures, review of the transfer log, review of on-call schedules and delineation of privileges, and interviews with paramedic, staff and physicians, the facility failed to provide medical treatment within its capacity that minimized the risk to the patient's health for 1 of 20 sampled patients. The facility also failed to complete a written Medical Certification to Transfer for Patient #1. This failure resulted in delay in treatment and resulted in potential harm including the possibility of respiratory distress, respiratory failure for Patient #1 on 4/24/19 at 6:20 PM. Refer to findings in Tag A-2409.


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Based on review of clinical medical records; review of Emergency Activity Log; review of audio recording and audio recording transcripts; Fire Rescue report review; facility Discharge Summary review; review of Physician Core Privileges; policies and procedures; interview with Emergency Medical Services (EMS) staff and physicians, the facility failed to provide stabilizing treatment as required, that was within the capability of the hospital Emergency Department for (#1) of 20 sampled patients who presented to the Emergency Department (ED) with an identified emergency medical condition. This failure resulted in delay in treatment and resulted in potential harm including the possibility of respiratory distress, and respiratory failure for Patient #1.


The findings include:


1) Emergency Activity Log

A review of the Emergency Activity Log revealed the patient presented to the AHPC facility on 4/24/19 at 6:20 PM. Further review of the ED Activity Log revealed in part, that Patient #1 was unstable and that his diagnoses was "Pneumothorax, bicycle accident, advanced age and Pulmonary Contusion." It was also documented that Patient #1 was discharged on 4/24/19 at 7:34 PM to Hospital B.


2) Medical Record Review Patient #1-Adventhealth Palm Coast (AHPC)

A review of AHPC emergency department medical record revealed Patient #1, a 72-year-old male was riding his bicycle when he struck an object. He flipped over the bicycle bar. He returned to his home. Three hours later, Patient #1 experienced chest pain and pain in his left shoulder. Emergency Medical Services was called.


Review of the AHPC hospital face sheet revealed the patient was self-pay. Patient #1 was triaged (process of sorting patients based on their need for immediate treatment) at an acuity level of 2 - "unstable". Vital signs were: heart rate - 87 beats/minute; respiratory rate - 26 breaths/minute; blood pressure - 138/79 mmHg, and a numerical pain assessment revealed the patient had 8/10 pain symptoms. Acute pain goal was documented as zero (0), and oxygen saturation rate was 92%. Patient #1 was also on 2 liters of oxygen per nasal cannula. A Medical Screening Examination (MSE) was completed.


Review of the AHPC MSE screening revealed respiratory status was normal; lungs clear to auscultation ((listening to the internal sounds of the body, usually using a stethoscope). Further review revealed in part, "Chest wall left post (posterior) extremely tender, no subcutaneous emphysema, no palpable deformity". Chest X-Ray showed multiple rib fractures, pulmonary contusion and subcutaneous air. Impression was suspected small left pneumothorax (air between the lung and the chest wall) due to multiple left-sided acute rib fractures. Fast ultrasound for blunt trauma was completed and it showed no sliding on the left. It was a normal exam. The patient was deemed medically cleared and was placed back into the ambulance and transferred to Hospital B emergency room immediately without any stabilizing treatments being performed for the pneumothorax.


According to the AHPC medical record, the documented condition was "Critical" and the disposition was documented, "Medically cleared, discharged: Given hemodynamic stability and adequate oxygen saturations; decision was made to hold off on chest until the patient reaches definitive care. EMS personnel capable of placing a decompression device if the patient has any issues with oxygen or blood pressure on route.
The documented "Medical Decision-Making" was "Trauma Team": Trauma criteria met, the patient was made a trauma transfer and transferred with lights and sirens by ground ambulance that delivered Patient #1 here to the trauma receiving facility". Hospital B; Physician C (ED physician at Hospital B) was notified.


3) Core Privileges Review - Physician A

The Core Privileges in Emergency Medicine for Physician A at AHPC was reviewed. The privileges revealed that Physician B was approved on 9/10/2018 by the Department Chair to perform a Thoracostomy (Chest tube insertion procedure) tube insertion.



4) Audio Recording Transcripts and Audio Recordings

While the patient was in the ambulance in route to Hospital B, the AHPC Physician A called Hospital B on 4/24/19 at 6:52 PM to say the patient (#1) was "coming" and that it was a Trauma Alert and not a transfer.
Continued listening to the audio recordings revealed that Physician B from Hospital B tried to explain to Physician A that Patient #1 was a transfer.



5) Fire/Rescue Run Report

A review of the Fire/Rescue run report documented the above ED visit to AHPC. The document continued a time on 04/24/2019 at 6:54 PM at destination, Emergency Room at Hospital B. It was documented in the run report that a trauma alert was declared by AHPC Physician A and Patient #1 was diverted to the trauma center. The patient was secured in a stretcher and placed in rescue without incident. Patient #1 was transported to Hospital B ED. The recommendation by AHPC Physician A to EMS Personnel was pain management and monitor respiratory. Patient was administered another 5 mg morphine throughout transport. Medical report was given over radio and faxed to Hospital B.



6) Medical Record Review for Hospital B - Patient #1

A review of the medical record emergency department trauma flow sheet for Patient #1 at Hospital B documented a trauma alert was called on 04/24/2019 at 6:52 PM and Patient #1 arrived on 04/24/2019 at 6:59 PM. Further review revealed the Trauma Surgeon (Physician B) was called and asked to come in at 6:53 PM. The Glasgow Coma Scale was (15). The patient's Glasgow Coma Score (GCS) documented the state of consciousness with a score up to 15. A score of 3 means deep unconsciousness and a score of 15 is alert and oriented. This scale is used following a head injury. Patient #1 was administered 10 mg morphine by EMS and Patient #1 was on 4 liters/minute oxygen delivered by nasal cannula and oxygen saturation rate was at 96%. Documented at B (breathing) was normal respiratory effort, clear right lung sounds and absent left lung sounds. A Chest X-ray was obtained at 7:01 PM and documented: "1. Extensive subcutaneous air is noted within the left chest wall and base of neck which is suggestive of probable left sided Pneumothorax; 2. Multiple bilateral rib fractures are noted; 3. Scattered infiltrates are noted within the left lung and right lung base which are non-specific. 4. Cardiomegaly (enlarged heart)." The trauma surgeon arrived to the ED at 7:05 PM. On 4/24/2019 at 7:15 PM it was documented that Hospital B's Physician B placed a 28 French Chest Tube left side with 35 ml of blood output. Laboratory tests were ordered. Patient #1 went to CT at 7:21 PM. Patient #1 was admitted to the Intensive Surgical Care Unit (ISC).


Documentation of the examination of the patient revealed in part, "Neck trachea midline. Crepitus in the left side of the neck...Respiratory: Diminished breath sounds to the left lung with crepitus to the left chest wall and a possible flail (segment of the rib cage breaks due to trauma and becomes detached from the chest wall-life threatening emergency)...Musculoskeletal:..but he is tender to palpation of the left scapula...Medical Decision-Making:..Medical Screen Exam Complete: Yes; Emergency Medical Condition: Yes."


Physician B at Hospital B dictated a note on 4/24/19 at 7:40 PM. He documented, "...reveals a 70-something year-old male gasping for breath. Chest: unilateral right breath sounds, none over lung left side. The patient is splinting. He has subcutaneous emphysema consistent with crepitation (a grating or crackling sound or sensation) under the left chest wall extending into the left neck. Patient at this point is gasping for air and is developing tension pneumothorax." The note continued, " Apparently, the Emergency Room C physician here (at Hospital B) got a call stating they will not treat the patient, but will divert the patient as a Priority Trauma Alert to us. Patient was at that point in the emergency room at AHPC being taken care of by a physician. The patient was therefore transferred to our institution with unstable respiratory system, with untreated hemopneumothorax (blood and air between the lung and chest wall), subcutaneous air and in respiratory distress. He stated, "I was never called to accept the patient and I discussed this with the ER physician." (Surveyor obtained a copy).


The physician documented that, "I called AHPC on the recorded line and discussed the care with AHPC, Physician A, the ER physician who referred the patient here. He stated that indeed, he would not accept the patient into his hospital because in his words, the patient needed to go to trauma hospital and therefore, he would not even allow the patient to get into the ER, but somehow he got in there and they did an ultrasound of the chest and established hemopneumothorax and then sent him to us. He appeared very proud, stating that he did not let the EMS leave because this patient does not belong in his hospital. He stated that he called trauma alert from his hospital and diverted the patient, rather than treat the patient and that this is how they have been taught to do things all along. He also stated that he did not place the chest tube because if the patient crashed an ambulance EMS will be able to do that on the way."


At Hospital B, the patient was transferred to the Intensive Care Surgical Unit (ICU) on 4/24/2019, and was placed on mechanical ventilation two days later. The patient was ultimately discharged to a Skilled Nursing Facility.


7) Interviews

An interview was conducted with Paramedic A on 05/16/2019 at 11:57 AM and he confirmed that Patient #1 did not meet the Adult Trauma Alert Criteria. The Paramedic stated that the patient was medicated for pain in the ambulance in route to AHPC and Hospital B with morphine for a total of 10 mgs.


An interview was conducted with AHPC Physician A on 05/16/2019 at 4:04 PM, and he recalled Patient #1. He confirmed that he sent Patient #1 to another facility without medical records, imaging results, and a physician's certificate authenticating the transfer. He stated that if the patient did not meet trauma alert on arrival, and as they work up the patient, status can be changed; then it would become a transfer.


AHPC Physician A discussed that there was a trauma alert criteria and Patient #1 met trauma alert from the "get go". AHPC Physician A confirmed that he just did a fast exam and focused assessment, and that EMS personnel suspected a pneumothorax in their initial assessment and fremitus (vibration intensity felt on the chest or heard with a stethoscope), and he confirmed this with his bedside ultrasound. AHPC Physician A also stated, "Certainly the patient is going to end up with the chest tube. He stated that the longer he kept the patient, the more likely the patient was going to die." He confirmed that he did not want to take the extra 10 minutes to insert a chest tube. AHPC Physician A confirmed with a trauma alert, "It is just a trauma alert and the patient just needs to go to the nearest facility". He stated that he called out of courtesy and that a trauma receiving facility is required to receive a trauma alert if the patient meets criteria and it is not even required that they be notified. The ambulance personnel will have a process to call the receiving facility on the way in. He stated that he would not have done this approach differently. AHPC was equipped with staff and such services and equipment necessary to stabilize Patient #1's emergency medical condition. The patient was subsequently transferred on 4/24/2019 to Hospital B, which was approximately 24 miles away.

It was documented in the AHPC ED Discharge Summary Patient #1 was discharged on 4/24/19 at 7:34 PM.


8) Policy and Procedure Review

A review of the facility Policy EM 025 "Care Decisions in Emergency Department" documented a purpose as "An assessment will determine what plan of care is required to meet the patient's initial needs and course of treatment during stay in the Emergency Department (ED).

A review of the facility policy EMTALA RM 014 documented at III Procedural Guidelines: "A. AHPC shall comply with the emergency care obligations imposed by EMTALA. Each person who comes to AHPC (or is within 250 yards) seeking emergency care will be provided with:

1. An appropriate medical screening examination;
2. Any necessary stabilizing treatment or;
3. An appropriate transfer to an accepting facility (if those services are not available at AHPC)."

The facility failed to ensure that their own policy and procedures were followed as evidenced by failing to provide necessary stabilizing treatment as required for Patient #1 on 4/24/2019.


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Based on Emergency Room medical record reviews; ED discharge summary review; Emergency Medical Services (EMS) report; audio recordings and phone transcript reviews; review of policy and procedures; review of the Transfer Log; review of on-call schedules and delineation of privileges; and interviews with paramedic, staff and physicians, the facility failed to provide medical treatment within its capacity that minimized the risk to the patient's health for 1 of 20 sampled patients. The facility also failed to complete a written Medical Certification to Transfer for Patient #1. This failure resulted in delay of treatment and resulted in potential harm including the possibility of respiratory distress and respiratory failure for Patient #1 on 4/24/19 at 6:20 PM.


The findings include:


1) Medical Record Review - Patient #1 at AHPC


A review of AHPC emergency department medical record revealed Patient #1, a 72-year-old-male was riding his bicycle when he struck an object. He flipped over the bicycle bar. He returned to his home. Three hours later, Patient #1 experienced chest pain and pain in his left shoulder. EMS was called. Review of the AHPC Emergency Activity Log revealed the patient presented to the facility on 4/24/19 at 6:20 PM. Review of the Face Sheet revealed the patient was self-pay. Patient #1 was triaged. Vital signs were heart rate - 87 beats/minute; respiratory rate - 26 breaths/minute; blood pressure - 138/79 mmHg, and a numerical pain assessment scale revealed the patient had 8/10 pain symptoms. Acute pain goal was documented as zero (0), oxygen saturation rate was 92%. A review of AHPC's emergency department medical record revealed that a Medical Screening Examination (MSE) was completed. Review of the MSE screening revealed respiratory status was normal; lungs clear to auscultation (listening to the internal sounds of the body, usually using a stethoscope). Chest X-Ray showed multiple rib fractures, pulmonary contusion and subcutaneous air. Impression was suspected small left pneumothorax due to multiple left-sided acute rib fractures. Fast ultrasound for blunt trauma was completed and it showed no sliding on the left. It was a normal exam. The patient was deemed medically cleared and was placed back into the ambulance and transferred to Hospital B emergency room immediately without any treatment.


According to the AHPC medical records, the documented condition was "Critical" and the disposition was documented, "Medically cleared, discharged: Given hemodynamic stability and adequate oxygen saturations, decision was made to hold off on chest until the patient reaches definitive care. EMS personnel capable of placing a decompression device if the patient had any issues with oxygen or blood pressure in route".


The documented "Medical Decision-Making" was Trauma Team: "Trauma criteria met, the patient was made a trauma transfer and transferred with lights and sirens by ground ambulance that delivered Patient #1 to the trauma receiving facility. Hospital B; Physician C was notified. Transcript of the phone conversation revealed while the patient was in the ambulance in route to Hospital B, the AHPC Physician A called Hospital B on 4/24/19 at 6:52 PM to say the patient was "coming," and that it was a Trauma Alert


2) ED Discharge Summary

It was documented in the AHPC ED Discharge Summary, Patient #1 was discharged on 4/24/19 at 7:34 PM.



3.) Interviews

An interview was conducted with Paramedic A on 05/16/2019 at 11:57 AM and he confirmed that Patient #1 did not meet the Adult Trauma Alert Criteria. The Paramedic stated that the patient was medicated for pain in the ambulance in route to AHPC and Hospital B with morphine for a total of 10 mgs. A second interview was conducted with EMS Paramedic A on 5/17/2019 at 11:57 AM and he confirmed he did not take any documentation for Patient #1 from AHPC.


An interview was conducted with AHPC Physician A on 05/16/2019 at 4:04 PM and he recalled Patient #1. He confirmed that he sent Patient #1 to another facility without medical records, imaging results, nor a physician's certificate authenticating the transfer. He stated that if the patient does not meet trauma alert on arrival; as they work up the patient, then it could become a transfer.


AHPC Physician A discussed that there was a trauma alert criteria and Patient #1 met trauma alert from the "get go". AHPC Physician A confirmed that he just did a fast exam and focused assessment and that EMS personnel suspected a pneumothorax in their initial assessment and fremitus (vibration intensity felt on the chest or heard with a stethoscope), and he confirmed this with his bedside ultrasound. AHPC Physician A also stated, "Certainly, the patient is going to end up with the chest tube". He stated that the longer he kept the patient, "the more likely the patient was going to die." He confirmed that he did not want to take the extra 10 minutes to insert a chest tube. AHPC Physician A confirmed with a trauma alert,..." It is just a trauma alert and the patient just needs to go to the nearest facility". He stated that he called out of courtesy and that a trauma receiving facility is required to receive a trauma alert if the patient meets criteria and it is not even required that they be notified. The ambulance personnel will have a process to call the receiving facility on the way in. He stated that he would not have done this approach differently.



AHPC Physician A called the surveyor via telephone, and he was interviewed on 05/17/2019 at 9:07 AM. During this interview, the physician was asked, why did he not send the medical records with the patient? The physician stated that by the time he burned a CD with X-ray results and inserted a chest tube, that would have delayed the care for Patient #1. He also stated that he understood that at the receiving facility (Hospital B), the patient did not receive the chest tube right away. He repeated that he did not want to add time to delay definitive care that was awaiting at the trauma center, and he did not want to use up the "golden hour" related to trauma care. He confirmed that he would not have done this differently and would do it again with the same situation.


According to an interview with the facility Risk Manager on 05/20/2019 at 4:58 PM, the total facility census was 123 patients (in-patients and observation patients) on 04/24/2019 at 7:00 AM. At 07:00 AM, the facility had 15 ICU patients (Leaving 3 ICU beds unoccupied) and 32 Progressive Care Unit (PCU) patients (Leaving 0 PCU beds unoccupied). At 7:00 PM on 04/24/2019, the facility's total census was 112 patients (in-patient and observation). At 7:00 PM, the facility had 13 ICU patients, leaving 5 ICU beds unoccupied and 29 PCU patients (Leaving 3 PCU beds unoccupied).

4.) Audio Recordings and Phone Conversation

The surveyor listened to the audio recording of the phone conversation between AHPC Physician A and the transfer center staff and Hospital B, Physician B. It was noted that AHPC Physician A and Hospital B Physician B discussed the nature of the patient's movement from the sending ED as a transfer and since Patient #1 was seen in the sending facility ED, the patient would be a transfer from the sending facility to the recipient facility (Hospital B). The audio recording revealed some back and forth discussion between transfer center staff and the recipient facility physician about the transfer status of Patient #1, and AHPC Physician A insisted that Patient #1 was on his way by ambulance to the recipient ED as a trauma alert. He stated, "Based on age and uh, and uh and the mechanism, you know, he's got two blues, he meets criteria, so they just loaded him back up and took him. So, he's a trauma alert coming and just wanted to let you know." Hospital B, Physician C repeated back to AHPC Physician A, "So he's a trauma transfer?" AHPC Physician A stated, "He is not a transfer, he is a trauma alert; we did an ultrasound and an X-ray and Patient #1 was diverted."

5.) Phone Transcript - Hospital B

A review of the recipient facility phone transcript confirmed that AHPC Physician A spoke with the recipient facility Hospital B Physician B and it was documented that AHPC Physician A stated, "Our guys bring people here and sometimes it is not appropriate, so we figure that out right away. Then, we activate the trauma alert system." [Surveyor obtained a copy.]


6.) Emergency Department Transfer Log

A review of the sending facility's Emergency Department Transfer Log documented on 04/24/2019 at 6:35 PM: "Patient was a trauma alert; no face sheet, no registration, no labs and no X-rays. Left hospital with County EMS Rescue."


7.) EMS County Fire Rescue Report

A review was conducted of the County Fire/Rescue run report, which documented the above ED visit to AHPC. The document contained a time on 04/24/2019 at 6:54 PM at destination, Emergency Room at Hospital B. It was documented in the run report that a trauma alert was declared by AHPC Physician A and Patient #1 was diverted to the trauma center. The patient was secured in a stretcher and placed in rescue without incident. Patient #1 was transported to Hospital B ED. The recommendation by AHPC Physician A to EMS Personnel was pain management and monitor respiratory. Patient was administered another 5 mg morphine throughout transport. Medical report was given over radio and faxed to Hospital B.


8.) Medical Record Review - Hospital B

A review of the emergency department trauma flow sheet for Patient #1 at Hospital B documented a trauma alert was called on 04/24/2019 at 6:52 PM, and Patient #1 arrived on 04/24/2019 at 6:59 PM. The Glasgow Coma Scale was (15). The patient's Glasgow Coma Score (GCS) documented the state of consciousness and scored up to 15. Three (3) means deeps unconsciousness;15 is alert and oriented. This scale is used following a head injury. Patient #1 was administered 10 mg morphine by EMS and Patient #1 was on 4 liters/minute oxygen delivered by nasal cannula and oxygen saturation rate was at 96%. Documented at B (breathing) was normal respiratory effort, clear right lung sounds and absent left lung sounds. On 04/24/2019 at 7:15 PM it was documented that Hospital B Physician B placed a 28 French Chest Tube left side with 25 ml of blood output. Patient #1 went to CT at 7:21 PM. Patient #1 was admitted to the Intensive Surgical Care Unit (ISC). Chest X-ray was obtained at 7:01 PM and documented 1. Extensive subcutaneous air is noted within the left chest wall and base of neck which is suggestive of probable left sided pneumothorax; 2. Multiple bilateral rib fractures are noted; 3. Scattered infiltrates are noted within the left lung and right lung base which are non-specific; 4. Cardiomegaly (enlarged heart).


Physician B at Hospital B dictated a note on 4/24/19 at 7:40 PM. He stated,... "reveals a 70-something-year-old male gasping for breath. Chest: unilateral right breath sounds, none over lung left side. The patient is splinting. He has subcutaneous emphysema consistent with crepitation (a grating or crackling sound or sensation) under the left chest wall extending into the left neck. Patient at this point is gasping for air and is developing tension pneumothorax". The note continued, "Apparently, the Emergency Room C physician here (at Hospital B) got a call stating they will not treat the patient, but will divert the patient as a Priority Trauma Alert to us. Patient was at that point in the emergency room at AHPC being taken care of by a physician. The patient was therefore transferred to our institution with unstable respiratory system, with untreated hemopneumothorax (blood and air between the lung and chest wall), subcutaneous air and in respiratory distress". He stated, "I was never called to accept the patient and I discussed this with the ER physician". (Surveyor obtained a copy).


The physician documented that, "I called AHPC on the recorded line and discussed the care with AHPC, Physician A, the ER physician who referred the patient here". He stated that indeed, he would not accept the patient into his hospital because in his words the patient needed to go to trauma hospital and therefore he would not even allow the patient to get into the ER, but somehow he got in there and they did an ultrasound of the chest and established hemopneumothorax and then sent him to us. He appeared very proud, stating that he did not let the EMS leave because this patient did not belong in his hospital. He stated that he called trauma alert from his hospital and diverted the patient rather than treat the patient and that this is how they have been taught to do things all along. He also stated that he did not place the chest tube because if the patient crashed, an ambulance EMS would be able to do that on the way.

At Hospital B, the patient was transferred to the Intensive Care Unit (ICU) and was on mechanical ventilation two days later. The patient was ultimately discharged to a Skilled Nursing Facility.


9.) Policy and Procedure Review

A review of the AHPC facility Policy EM 025, "Care Decisions in Emergency Department" documented a purpose as "An assessment will determine what plan of care is required to meet the patient's initial needs and course of treatment during stay in the Emergency Department (ED)."

A review of the AHPC facility Policy "1000.032" documented under the "purpose" of the policy was to "expedite the patient transfer and admission process in a manner consistent with the needs of our patients excluding Baker Acts. Transfer patients are defined as patients that a referring facility does not have the capability or capacity required to care for the patient at the time and is in medical need to be transferred to a facility that does have those required capabilities or capacity. These transferring patients will have a pre-arranged in-patient bed assignment and do not require Emergency Department services. Emergency Department (ED) to ED transfers will be facilitated through AHPC Transfer Center if the patient still requires emergency department services. The Transfer Center will facilitate this transfer to any tertiary center appropriate for the patient needs. Purpose: Patients transferred to an accepting facility must meet the following conditions: 1. The patients meet criteria for admission; 2. The patient has been accepted by an attending physician or physician on call with appropriate admitting privileges at the accepting facility; 3. The hospitalist/intensivist service to which the patient will be admitted must be informed of the admission by the Transfer Center Supervisor and have the ability to communicate with consulting or referring physician; 4. Transfer Coordinator will also request any images, radiology reads, studies that have been completed on the patient and a discharge summary to be sent with the patient to the facility."


10.) Delineation of Privileges Review

A review of the delineation of Privileges for AHPC Physician A who cared for Patient #1 supported that this physician had core privileges in emergency medicine which included, "Assess, evaluate, diagnose and initially treat patients of all ages who present in the ED with any symptom, illness, injury or condition and provide services necessary to ameliorate minor illness or injuries; stabilize patients with major illnesses or injuries and to assess all patients to determine if additional care is necessary. Procedures approved by the department chair on 09/10/2018 at 1:31 AM included "Thoracentesis (needle is inserted into the pleural space between the lungs and the chest wall), Thoracostomy tube insertion (incision into the chest wall and a tube is placed into the space between the lung and the chest wall), and Thoracotomy (a cut made between the ribs)."



11.) On-Call Schedule Review

A review of the facility "Call Schedule" for April 2019; updated on 04/24/2019 documented that Cardiology, Critical Care, GI, General Surgery, Pulmonary Medicine and Thoracic Surgery were available. Advent Health Palm Coast had the capability and capacity to provide the needed care for Patient #1 on 4/24/2019, as this resulted in an inappropriate transfer for Patient #1. At the time of the transfer the risks were greater than the benefits. The patient was not stable at the time of the transfer.