HospitalInspections.org

Based on review of patient medical records, hospital policies and procedures, in hospital services provided (Florida Health Fnder.gov) incident reports, EMS care reports emergency medical services records, Sheriff's Department records, and patient and staff interviews, the hospital failed to ensure that an appropriate medical screening examination (MSE) was provided that was within the capability of the hospital's emergency department, to include ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed when the Individual ( #21)arrived on the hospital 's property via ambulance. The individual was diverted to another acute care hospital; the hospital also failed to ensure that an appropriate medical screening examination was provided for an individual (#20) by failing to address the individual 's complaint of pain. The hospital failed to ensure that appropriate medical screening examinations were provided for 2 (#20 and #21) of 21 sampled patient medical records reviewed. Refer to findings in Tag A-2406.

-Based on patient interview, record review and review of policy and procedures, the hospital failed to provide medical treatment that was within its capacity that minimize the risks to the individuals health by failing to perform a Medical Screening Exam (MSE) and stabilize a patient before transferring that patient to another hospital for 1 (Patient #21) of 21 patients medical records reviewed who presented to the hospital seeking emergency services after a fall. Refer to findings in Tag A-2409.

Based on review of the ED Log, Emergency Medical Services (EMS) Patient Care Report, Incidents Reports, EMS Communication Sheets, Automatic Vehicle Location report, and patient interview, the hospital failed to maintain a Central Emergency Room (ER) Log of all patients who came to the ER requesting medical services and their disposition for 1 (Patient #21) of 21 patients reviewed who came to the emergency room and requested services.


The findings include:


Review of the _____ County EMS Patient Care Report, dated 10/3/15, revealed they arrived at the Patient #21's home where the patient was complaining of pain in his right shoulder after a trip and fall over a parking curb. EMS transported the patient to Florida Hospital Memorial Medical Center (also referred to as 703 by EMS). EMS notified the Emergency Room (ER) of the patient with a right shoulder dislocation.


Review of the ______ County Incident Report dated 10/22/15, describing EMS run on 10/3/15 revealed Patient #21 had "obvious right shoulder dislocation." After report was given and repeated, "Female voice came back up on radio and stated per Dr. [Staff A], if Pt. was trauma alert to divert to 704 (referred to as the second hospital), but if not trauma alert, proceed to 703. I pulled into ambulance bay at 703 when female's voice came back up on the med channel and stated for Pt. to be diverted to 704 as trauma alert, ... continued out of ramp at 703 ..." Patient #21 was diverted to the second hospital.


Review of a second ______ County Incident Report describing EMS run on 10/3/15, revealed Patient #21 "had obvious dislocated right shoulder with absent pulses noted in arm." The patient was transported to "the closest hospital, 703, which is less than 1 mile from scene." Report was given and repeated. "703 advised Pt. was a trauma alert and to divert." Patient #21 was diverted to the second hospital.


On 10/19/15, during an interview at about 11:00 a.m., Patient #21 spoke about his fall and arm pain. He said that he lives next door to the hospital. He stated that he lives about 250 yards from the hospital and was waiting in the ambulance to go into the hospital, when the ambulance driver had to drive to a second hospital.

Review of hospital's Emergency Room Log failed to show that Patient #21 had come to the emergency room and requested medical services and was refused treatment. Review of a hospital EMS Communication Sheet revealed an untimed entry for a 65 year-old male with chief complaint of "R[ight] upper arm & shoulder 0 pulse on R[ight]". There was no other information to show disposition of the patient.


Review of the Automatic Vehicle Location (AVL) tracking system utilized by the Sheriff's Office and EMS showed the geographic location of the ambulance that transported Patient #21 on 10/3/15 to Florida Hospital Memorial Medical Center. The AVL showed and validated that the EMS ambulance was at patient #21's home and, then at the ambulance entrance of Florida Hospital Memorial Medical Center on 10/13/2015. The AVL then showed and validated the EMS ambulance leaving 703's property and driving south to the second hospital (704). Patient #21 was transported to the hospital's property, was refused treatment, but was not recorded in the ER Log.

Based on review of patient medical records, hospital policies and procedures, in hospital services provided (Florida Health Finder.gov) incident reports, EMS care reports emergency medical services records, Sheriff's Department records, and patient and staff interviews-, the hospital failed to ensure that an appropriate Medical Screening Examination (MSE) was provided that was within the capability of the hospital's emergency department, to include ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed when the Individual ( #21) arrived on the hospital ' s property via ambulance. The individual was diverted to another acute care hospital; the hospital also failed to ensure that an appropriate Medical Screening Examination was provided for an individual (#20) by failing to address the individual ' s complaint of pain. The hospital failed to ensure that appropriate medical screening examinations were provided for 2 (#20 and #21) of 21 sampled patient medical records reviewed.


The findings include:


Review of Florida Health Finder.gov shows the hospital services include an Emergency Department. Emergency services offered includes: Anesthesia; Cardiology; Cardiovascular Surgery; Colon & Rectal Surgery; Emergency Medicine; Endocrinology; Gastroenterology; General Surgery; Gynecology; Hematology; Internal Medicine; Nephrology; Neurology; Neurosurgery; Obstetrics; Ophthalmology; Orthopedics; Otolaryngology; Plastic Surgery; Podiatry; Pulmonary Medicine; Radiology; Thoracic Surgery; Urology, and Vascular Surgery.


The hospital's MSE ("Medical Screening Examination " ) Process Protocol (Page 1) stated, "Any patient who comes to the emergency department requesting examination or treatment for a medical condition must be provided with an appropriate medical screening examination by a qualified medical provider to determine if one is suffering from an emergency medical condition. It is necessary that any person deemed as having an emergency medical condition be provided with stabilizing medical treatment." Further review of Hospital's Policy stated in part, " Policy: To provide all patients who present to the Emergency Department for medical treatment with a medical screening exam (MSE) by a qualified medical provider in accordance with current hospital policies ...Procedure: The medical screening examination must be performed on all patients who present to the Emergency Department and request medical care. A triage nurse who determines the order in which patients are provided medical screening exams initially sees a patient that presents to the Emergency Department. "


The ________ County EMS Patient Care Report, dated 10/3/15, stated in the narrative section of the EMS report in part,"Upon hailing 703 on the medical channel, med unit was diverted from original facility, 703, to 704 by 703 ER physician, based on Dr. [Staff A], 'Patient meeting trauma alert criteria.' 703 was advised over the med channel that no trauma alert was called by [county] EMS or [local] Fire Rescue and pt. in-fact does not meet [county] nor National Registry Guidelines as trauma alert criteria ... Once at 704, Pt. care was turned over to ER staff ... "


Review of _________ County Incident Report dated 10/22/15 describing EMS run on 10/3/15 revealed Patient #21 had "obvious right shoulder dislocation." After report was given and repeated, "Female voice came back up on radio and stated per Dr. [Staff A], if pt. was trauma alert to divert to 704, but if not trauma alert, proceed to 703. I pulled into ambulance bay at 703 when female's voice came back up on the med channel and states for pt. to be diverted to 704 as trauma alert, continued out of ramp at 703 ... " Patient #21 was diverted to the second hospital and did not receive a medical screening examination at Florida Hospital Memorial Medical Center.


Review of a second ________ County Incident Report describing EMS run on 10/3/15, revealed Patient #21 "had obvious dislocated right shoulder with absent pulses noted in arm." The patient was transported to "the closest hospital, 703, which is less than 1 mile from scene." Report was given and repeated. "703 advised Pt. was a trauma alert and to divert." Patient #21 was diverted to 704, the second hospital.


Patient #21's medical record from the second acute care hospital (704) was reviewed. The review of the medical record revealed that Patient #21 arrived via ambulance on 10/3/2015 at 1:03 p.m. The patients Chief Complaint was, the patient tripped and fell on a curb in his apartment complex and fell on an outstretched right hand. The Medial Screening Examination was provided by the ED physician. The differential diagnosis was, Shoulder dislocation, humerus facture, arterial injury, dissection, brachial plexus injury or neurapraxia. Screening included the following: Pt placed on monitor, IV ' s, blood obtained, x-ray of humerus and shoulder. The stabilizing treatment provided for Patient #21 was that he was sedated and dislocation reduction was performed. The follow-up CT showed normal vasculature of the right upper extremity without evidence of dissection, and a Humeral head fracture. Patient #21 was discharged home with follow-up care and medications were ordered for pain.


On 10/19/15, during an interview at approximately 11:00 a.m., Patient #21 spoke about his fall and arm pain. He did not understand why he was considered a trauma alert case and could not be treated at the hospital. He said his family thought he was at the nearby hospital (Florida Hospital Memorial Medical Center) and went there to see him and were told that he was taken to the second hospital.


During an interview on 10/20/2015 at 11:30 a.m. with Mr. H (Emergency Operations Manager), provided a CD recording of the conversation that occurred between the EMS paramedics and the Florida Hospital Memorial Medical Center. The CD revealed the EMS paramedic informing Florida Hospital Memorial Medical Center there was no trauma criteria met.


In an interview with Dr. Staff A (ED physician on duty in the when Patient #21 presented to the ED) on 10/20/15 at 4:15 p.m., he said that he understood the EMS paramedic to say the patient had a pulseless extremity and long bone fracture. The doctor said the paramedic said the patient was over 55 with a long bone fracture, and that meant he met trauma alert criteria. Dr. Staff A then told EMS, "If the patient meets trauma criteria, he will be better served at the trauma center." During the interview Dr. A called Dr. B (Medical Director of the ED). Dr. B stated that he remembers the case and they did divert the transfer. The facility failed to ensure that an appropriate medical screening examination was provided to determine whether or not an emergency medical condition existed for Patient #21 on 10/3/2015 as evidenced by Patient #21 was never off-loaded from the EMS ambulance on the hospital ' s ramp. Dr. Staff A directed EMS to go to the second hospital on 10/3/2015.


Patient #20's medical record was reviewed. The medical record revealed that Patient #20 presented to the ED as a walk-in on 10/4/2015 at 5:47 p.m., via private car accompanied by her husband. Review of the Emergency Department Triage Form dated 10/4/2015 revealed that the patient was triaged at 5:52 p.m. The patient ' s chief compliant was, " neck pain ...Chief Complaint comment Pt seen on the 10/02/2015 for same issue. " Patient #20's vital signs were listed as Blood Pressure: 106/65; Pulse-64; Respirations: 18; Oral Temperature: 98.1; Oxygen Saturation; 98%. The patient 's pain assessment/pain score was "10." (On a pain scale of 0 (no pain)-10 with 10 worst /excruciating pain).
Review of the Emergency Room Record Medical Screening Examination revealed that Patient #20 was seen by the PA-C Physician's Assistant) at 6:02 p.m. The PA-C documented in the section titled History of Present Illness (HPI) revealed in part, " The patient presents with chronic neck. The onset was chronic ... Review of Systems: Musculoskeletal symptoms: Negative except as documented in HPI...Physical Examination: Neck: Supple, ...Tenderness: Diffuse, posterior ...Procedure notes: Patient was very threatening and had to be escorted out with security. Stated she would leave and come back by ambulance. She was told would be MSE (medical screening examination) again. Impression and Plan: Diagnosis Encounter for medical screening examination ...Condition: Stable Disposition: Discharge. " Review of the Certification of Medical Screening Examination dated 10/4/2015 at 5:54 p.m., the PA-C documented, " NO EMERGENCY MEDICAL CONDITION: The patient DOES NOT HAVE an emergency medical condition and may be referred to/for other resources. "Review of the Patient Acknowledgement after Medical Screening Examination form dated 10/4/2015 at 6:15 p.m., indicated in part, Our medical provider has been determined that your condition does not require Emergency Department care. You may choose to go ahead and register to be seen here, follow up with your primary care physician, or be seen by another healthcare resource. Florida Hospital Memorial Medical Center Emergency Department will provide you with a list of Community resources ..... Please select your choice ...I choose to seek follow-up care on my own, outside of this hospital. I have read and understand the above ... " Documentation revealed that Patient #20 refused to sign the form, and the only other signature on the form was that of the Pa-C. There was no documentation in the medical record to indicate that Patient #20's neck pain score of 10 was addressed/treated during the medical screening examination process.


Florida Hospital Memorial Medical Center Incident report dated 10/4/2015 a 6:05 p.m. was reviewed. The Security Guard, documented that the registration asked him/her to assist with Patient #20 in a room where a patient was medically screened and " Had been asked to leave and were refusing. "The Security Guard went into the room (Pt #20 was in the room) along with another Security Officer (SO) and asked that they (Patient #20 and Husband) because it was determined that Patient #20 was not a medical emergency. The Security Guard documented. Patient #20 " Stated that she was here a couple of days ago and they had told her if the pain got worse to return and she did. She was complaining that a doctor had not seen her. So I explained to her that if she paid [sic- paid] the co pay she could be seen. She refused so her husband asked if we could get a wheelchair to assist her. S/O ...got a wheelchair and (Security Guard) rolled her outside. " The patient then called her mother via cell phone and informed her as to what had occurred at the hospital. Patient #20's mother agreed to pay the co pay with a credit card. The Security Guard wheeled Patient #20 back in and got the OK from registration that the patient's mother would be making the credit card payment to be seen for further treatment. Patient #20 then said an " expletive word " and requested that she be wheeled back outside. Further documentation revealed that Patient #20 decided to go elsewhere, saying " she would call 911 and have evac bring her back. "


The medical record from the hospital where Patient #20 presented to after leaving Florida Hospital Memorial Medical Center was reviewed. The medical record from the other acute care hospital revealed that Patient #20 presented to the hospital on 10/4/2015 at 7:10 p.m. via private. The Medical Screening Examination was completed by the ED physician and an emergency medical condition was identified. The diagnosis was cervical radiculopathy. The patient was administered the following medications Decadron (medication used to treat inflammatory conditions) 8mg IM and Noraflex (muscle relaxant) 60 mg IM. The patient was discharged home, with follow-up care instructions, prescriptions and to see her Primary Care Physician in a week.

During an interview with Employee F (Chief Financial Officer) on 10/9/2015 at 12:15 p.m., she explained the reason Medicaid Patients who are triaged; medical screening examinations completed that are determined by the physician to be non-emergency cases are offered non-emergency room treatment for a nominal fee of $150.00. She stated that when these services are provided, they often don' t cover the real cost of services.

The facility failed to ensure that an appropriate Medical Screening Examination was provided for Patient #20 on 10/4/2015, as evidenced by failing to provide further evaluation of the patients' complaint of " neck pain 10/10 " unless a co-pay was received.

Based on patient interview, record review and review of policy and procedures, the hospital failed to provide medical treatment that was within its capacity that minimize the risks to the individuals health by failing to perform a Medical Screening Exam (MSE) and stabilize a patient before transferring that patient to another hospital for 1 (Patient #21) of 21 patients medical records reviewed who presented to the hospital seeking emergency services after a fall.


The findings include:


The hospital's policy titled "Medical Screening Exam" (MSE) stated, "Any patient who comes to the emergency department requesting examination or treatment for a medical condition must be provided with an appropriate medical screening examination by a qualified medical provider to determine if one is suffering from an emergency medical condition. It is necessary that any person deemed as having an emergency medical condition be provided with stabilizing medical treatment."


Review of the_____ County EMS Patient Care Report, dated 10/3/15, revealed they arrived at the patient's home where the patient was complaining of pain in his right shoulder after a trip and fall over a parking curb. EMS transported the patient to the hospital (referred to as 703 by EMS). EMS notified the Emergency Room (ER) of the patient with a right shoulder dislocation. The narrative section of the EMS Report stated " Upon hailing 703 on the medical channel, med unit was diverted from original facility, 703, to 704 by 703 ER physician based on Dr. [Staff A], ' Patient meeting trauma alert criteria.' 703 was advised over the med channel that no trauma alert was called by [county] EMS or [local] Fire Rescue and patient, in fact, does not meet [county] nor National Registry Guidelines as trauma alert criteria ... Once at 704, Pt. care was turned over to ER staff ..." Florida Hospital Memorial Medical Center inappropriately transferred patient #21 on 10/3/2015 when the EMS ambulance arrived on the hospital ' s property seeking medical assistance for the patient who had a fall, the EMS ambulance personnel were directed to transfer Patient #21 to second hospital prior to an medical screening examination or stabilizing treatment. The hospital ' s failure to ensure that their policy and procedure was followed as evidenced by failing to ensure that an appropriate medical screening examination was provided by a qualified medical personnel (Physician, PA-C) and stabilizing treatment that was within the capacity to minimize the risks to Patient #21 health and safety on 10/3/2015. As this resulted in a inappropriate transfer for patient #21 on 10/3/2015.


An interview was conducted with Patient #21 on 10/19/2015 at approximately 11:00 a.m. He stated that he lives about 250 yards from the hospital (Florida Hospital Memorial Medical Center) and was waiting in the ambulance to go into the hospital when the ambulance driver had to drive to a second hospital.