HospitalInspections.org

Based on record review and interview, the facility failed ensure sampled patient #1 (SP #1) who was an incoming transfer was provided a medical screening examination when she presented to the facility. Sampled patient #1 is one of twenty-three sampled patients who presented to the facility for a medical screening examination. The patient had a diagnosis of a Myocardial Infarction. Refer to A2406.

Based on reviews of medical records, policies and procedures, transfer logs, surveillance video, local ambulance run sheet, e-mails, Air Ambulance Progress Review and interviews, the facility failed to ensure sampled patient #1 (SP #1) who was an incoming transfer was provided a medical screening examination when she presented to the facility. Sampled patient #1 is one of twenty-three sampled patients who presented to the facility for a medical screening examination. The patient had a diagnosis of a Myocardial Infarction and was in need of a interventional catheter lab for a cardiac stent.


The findings included:

Review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) -Florida Medical Screening Examination and Stabilization policy," dated 03/01/13, stated that the hospital must provide an appropriate medical screening examination to determine whether or not an emergency condition exists to any individual who requests such an examination or an individual who has such a request made on his or her behalf. The policy also documented that if an individual arrives as a transfer from another hospital or health care facility, upon arrival of a transfer, a physician or qualified medical person must perform an appropriate medical screening examination. The medical screening of the individual must be documented. The policy further documents, such obligation is further extended to those individuals presenting elsewhere on the hospital property requesting examination or treatment.


The medical record for SP (#1) from Hospital #2 was reviewed. Review of the section titled " Patient Demographic " indicated that SP#1 was a 64 year old individual with an address in another City and State in the United States of America. Further review of the medical record indicated that SP (#1) arrived at Hospital #2 on 3/7/2015 at 1:23 a.m., as " urgent. " SP#1's Chief Complaint " Patient presents with Chest Pain. " The patient's initial Vital Signs were Temperature 36.8; Heart rate: 65; Respirations: 18; Blood Pressure: 133/77; oxygen saturation- 98% and pain scale was 5. The physical examination revealed in part, " ...Cardiovascular: Normal rate regular rhythm, normal heart sounds, and intact distal pulses ... Cervical back she exhibits tenderness. L (left) cervical paraspinal tenderness ... Laboratory Evaluation: CBC with Diff - Abnormal ...Basic Metabolic Panel: Abnormal ...Clinical Impression: Diagnoses Headache ...Neck pain on left side Cervical disc herniation Cervical radiculopathy Palpitations ...ED Disposition: Disposition: Admit: Discussed ER findings, diagnosis and treatment plan. Informed on plan for admission for further evaluation and treatment... This patient had an emergency medical condition: yes. "


On 03/18/15 at 9:51 AM, the Vice President (VP) of Quality Management stated, sampled Patient (SP)#1 was transferred from the Island of Anguilla which is a part of the British territory. She stated, the transfer process was not finalized between the two facilities, and the sending hospital did not notify the facility that the patient was en route to the facility. She stated that last weekend around midnight an ambulance arrived to the Emergency Room (ER) but did not park where the vehicle was visible. They parked on the end of the curve. She stated, the paramedic staff came into the ER without the patient and asked for the nursing supervisor. She stated that the nursing supervisor and the ER staff did not know that the patient was outside the facility in the ambulance. She stated that after the ambulance staff left the facility, the ambulance staff called the physician who was accepting the patient and stated that they were taking the patient to Hospital #2 because the facility did not accept the case.

Review of the "Travel Instructions -Air Ambulance" indicated that (SP) #1 diagnosis was Acute Myocardial Infarction (Heart Attack) and EKG and labs were completed. The patient's acuity was listed as " Emergent. " The patient's destination facility was Aventura Hospital in Aventura, Florida. Record review of the Air Ambulance Progress Review showed that on 03/06/15 at 4:15PM, the air ambulance contacted the hospitals (Aventura Hospital and Medical Center) nursing supervisor who was the receiving nurse and the patient's clinicals were faxed.

Record review of the local ambulance Run Sheet dated 03/07/15 at 12:33AM revealed, "crew advising ... Hosp (Hospital) is not accepting this pt (patient) now due to an insurance issue. The flt (flight) medic is trying to resolve the issue-crew advising that the patient is still in their unit." On 03/07/15 at 12:58AM, per flight crew rerouting to (Hospital #2).

Review of a fax from SP#1's insurance carrier to the nursing supervisor at ... Hospital, on 03/06/15, the fax documented the patient's anticipated arrival time will be at 12:45AM on March 7, 2015 being delivered by [name] Air Ambulance.

Review of the SP #1's medical update from the insurance carrier [name] to [name] Hospital and dated 3/6/15 revealed, the patient was given a diagnosis of a Myocardial Infarction on 3/6/15 while on the Island of Anguilla. The patient had the onset of symptoms on 2/26/15.


Review of an email provided by the VP of Quality dated 03/10/2015, from the local ambulance company revealed SP #1 was transported to the hospital, and documented according to the EMT (emergency medical technician) during transport, a member of the flight crew was on the phone with the hospital trying to solidify the admission because they were previously aware of an insurance issue. The email further documents this conversation was not successful, so upon arrival to the hospital, one member of the flight team went into the hospital in an attempt to get resolution. The email documented, our crew, the patient, other team member, and a family member stayed in the ambulance waiting for more solid information. They waited about one half hour to 45 minutes. During the wait, the family member got restless and wanted to know what was going on. Our driver took the family member into the hospital to meet up with the flight crew member. The email documented, when the flight crew came out, he directed our crew to take the patient to hospital #2 because he was being told that the patient's insurance would not cover the patient being admitted to the hospital. The patient was transported to hospital #2.


During interview on 03/18/15 at 1:30PM with the ER physician, revealed he worked for the patient's insurance company (name) He reported, that the insurance company provides insurance to business and cruise ship travelers. He stated, the insurance company makes the transfer arrangements for patients, including communication with hospital staff. He stated, Travel Guard had offices all over the world, including one in Houston, Texas. He stated that, this facility accepts everything. He stated, SP#1 lived in the United States and was probably on vacation on the Island of Anguilla. He stated, SP#1 was already accepted and the facility was waiting for confirmation of arrival time. However, before he left the facility, the Friday evening around twelve midnight, he called the insurance company's On-call, to get an estimated time of arrival for the patient. He stated, the insurance company told him that the patient was no longer coming to this facility and that the patient was going to another acute care hospital. He stated, he never got a call from the air ambulance staff regarding the patient's transfer. He stated, usually, the air ambulance calls and informs the Travel insurance company with an estimated time of arrival. He stated that the air ambulance did not communicate with the insurance company regarding the transfer, which was unusual. He stated, he was not in the ER when the ambulance staff arrived. He found out that the patient was outside in the ambulance, when he returned to the ER the following morning.

During interview on 03/18/15 at 2:08 PM, the nursing supervisor reported, before international patients are transferred to the facility she verifies the patient's insurance information and provides acceptance for the patients. She stated, before air ambulance staff brings patients to the facility, they usually call and inform the facility about an estimated time of arrival. She reported for SP#1, the patient's insurance information was still in process of being verified. She stated, she had spoken with an insurance provider representative earlier that night and had asked them for a down payment for the patient because the facility was unable to verify SP#1's insurance. She stated, the insurance provider representative never called back regarding the down payment. She stated, the same night one of the facility's staff told her that there was a gentleman in the ER who wanted to talk to me. She stated, the gentleman was wearing a shirt with a [name] Logo. She stated that she thought the gentleman was from the airline that was making travel arrangements for SP#1. She stated, at no point did it cross her mind that the patient was outside because the gentleman did not tell her that. She stated, the gentleman asked what we were going to do for the patient. When she asked which patient, he said the name of SP#1. She stated, she told the gentleman to hold on while she went to check with registration. However, when she returned, the gentleman was gone. She stated, the gentleman did not bring the patient inside the facility nor did he say that the patient was outside. She stated, after the gentleman had left, she received a call from the physician who told her that the patient was outside. She stated, she called [name of air ambulance company] and asked them to bring the patient back. However, they stated that they were taking the patient to Hospital #2.

On 03/18/15 at 2:48 PM, the facility's surveillance video of the ER was reviewed. Review of the video showed that on 03/07/15 at 12:22AM, the ambulance arrived to the ambulance ramp. A Paramedic entered the ambulance entrance, spoke to facility staff. On 12:27 AM - on phone, 12:30 AM - goes outside to ambulance, 12:57 AM departed. However, it was observed the ambulance was parked away from the ambulance entrance. The video did not show the patient was carried into the ER by the ambulance staff. The video showed an individual, identified by the facility as the patient's family member, departed from the ambulance and went inside the ER. The individual talked with the ambulance staff inside the ER and then went back into the ambulance.

During interview on 03/18/15 at 3:24 PM, the accepting physician for SP#1 reported, he had received a call, from the facility, the day before the patient was transferred. He stated, he knew that the patient was coming at some point and that he had accepted the patient. He stated, around 1:00 AM, on the day of the incident (March 7, 2015), he got a call from the insurance company stating that the patient was outside and not being let into the facility. He stated, he called the ER and spoke with the nursing supervisor who told him that she was not aware that the patient was outside the facility. He reported, the nursing supervisor stated, when she came back from registration, the ambulance staff had left the hospital.


During interview on 03/18/15 at 3:46PM, Staff A, the ER Registrar, stated that when patients are being transferred via air ambulance, air ambulance sends a fax to the nursing supervisor, who then follows up with registration. She stated, registration would then verify the insurance after which the nursing supervisor would give confirmation of acceptance to the air ambulance. She stated, when the nursing supervisor came to her that night, she called the insurance company to verify SP#1's insurance, but no one answered. Staff A stated, she did not know that SP#1 was at the facility, outside in the ambulance. She stated, if the patient was at the facility, the patient would be accepted and insurance details would be verified later.

During interview on 03/18/15 at 4:01PM, Staff B, the ER Charge Nurse stated, when the air ambulance staff for SP#1 came to the registration desk, he asked for the nursing supervisor by name. She stated that the ambulance staff did not bring any patient inside. She stated, she was not directly involved in the conversation between the nursing supervisor and the air ambulance staff. However, since she was at the charge nurse desk, she could over hear the conversation. She stated, the air ambulance staff did not mention to the nursing supervisor or to the ER staff that the patient was outside the facility. She stated, if the patient was outside, the facility would have accepted the patient.

Review of the facility's Transfer Log from November 2014 to present did not show the name of SP#1. Review of the facility's ER log from for March 1-18, 2015, did not show that SP#1 presented to the ER.

The facility failed to ensure that on 3/7/2015 SP#1 received an appropriate medical screening examination when he/she presented to the hospital's property.

Based on reviews of medical records, policies and procedures, transfer logs, surveillance video, local ambulance run sheet, e-mails, Air Ambulance Progress Review and interviews, the facility failed to ensure sampled patient #1 (SP #1) who was an incoming transfer was provided a medical screening examination when she presented to the facility. Sampled patient #1 is one of twenty-three sampled patients who presented to the facility for a medical screening examination. The patient had a diagnosis of a Myocardial Infarction and was in need of a interventional catheter lab for a cardiac stent.


The findings included:

Review of the facility's policy titled, "EMTALA (Emergency Medical Treatment and Labor Act) -Florida Medical Screening Examination and Stabilization policy," dated 03/01/13, stated that the hospital must provide an appropriate medical screening examination to determine whether or not an emergency condition exists to any individual who requests such an examination or an individual who has such a request made on his or her behalf. The policy also documented that if an individual arrives as a transfer from another hospital or health care facility, upon arrival of a transfer, a physician or qualified medical person must perform an appropriate medical screening examination. The medical screening of the individual must be documented. The policy further documents, such obligation is further extended to those individuals presenting elsewhere on the hospital property requesting examination or treatment.


The medical record for SP (#1) from Hospital #2 was reviewed. Review of the section titled " Patient Demographic " indicated that SP#1 was a 64 year old individual with an address in another City and State in the United States of America. Further review of the medical record indicated that SP (#1) arrived at Hospital #2 on 3/7/2015 at 1:23 a.m., as " urgent. " SP#1's Chief Complaint " Patient presents with Chest Pain. " The patient's initial Vital Signs were Temperature 36.8; Heart rate: 65; Respirations: 18; Blood Pressure: 133/77; oxygen saturation- 98% and pain scale was 5. The physical examination revealed in part, " ...Cardiovascular: Normal rate regular rhythm, normal heart sounds, and intact distal pulses ... Cervical back she exhibits tenderness. L (left) cervical paraspinal tenderness ... Laboratory Evaluation: CBC with Diff - Abnormal ...Basic Metabolic Panel: Abnormal ...Clinical Impression: Diagnoses Headache ...Neck pain on left side Cervical disc herniation Cervical radiculopathy Palpitations ...ED Disposition: Disposition: Admit: Discussed ER findings, diagnosis and treatment plan. Informed on plan for admission for further evaluation and treatment... This patient had an emergency medical condition: yes. "


On 03/18/15 at 9:51 AM, the Vice President (VP) of Quality Management stated, sampled Patient (SP)#1 was transferred from the Island of Anguilla which is a part of the British territory. She stated, the transfer process was not finalized between the two facilities, and the sending hospital did not notify the facility that the patient was en route to the facility. She stated that last weekend around midnight an ambulance arrived to the Emergency Room (ER) but did not park where the vehicle was visible. They parked on the end of the curve. She stated, the paramedic staff came into the ER without the patient and asked for the nursing supervisor. She stated that the nursing supervisor and the ER staff did not know that the patient was outside the facility in the ambulance. She stated that after the ambulance staff left the facility, the ambulance staff called the physician who was accepting the patient and stated that they were taking the patient to Hospital #2 because the facility did not accept the case.

Review of the "Travel Instructions -Air Ambulance" indicated that (SP) #1 diagnosis was Acute Myocardial Infarction (Heart Attack) and EKG and labs were completed. The patient's acuity was listed as " Emergent. " The patient's destination facility was Aventura Hospital in Aventura, Florida. Record review of the Air Ambulance Progress Review showed that on 03/06/15 at 4:15PM, the air ambulance contacted the hospitals (Aventura Hospital and Medical Center) nursing supervisor who was the receiving nurse and the patient's clinicals were faxed.

Record review of the local ambulance Run Sheet dated 03/07/15 at 12:33AM revealed, "crew advising ... Hosp (Hospital) is not accepting this pt (patient) now due to an insurance issue. The flt (flight) medic is trying to resolve the issue-crew advising that the patient is still in their unit." On 03/07/15 at 12:58AM, per flight crew rerouting to (Hospital #2).

Review of a fax from SP#1's insurance carrier to the nursing supervisor at ... Hospital, on 03/06/15, the fax documented the patient's anticipated arrival time will be at 12:45AM on March 7, 2015 being delivered by [name] Air Ambulance.

Review of the SP #1's medical update from the insurance carrier [name] to [name] Hospital and dated 3/6/15 revealed, the patient was given a diagnosis of a Myocardial Infarction on 3/6/15 while on the Island of Anguilla. The patient had the onset of symptoms on 2/26/15.


Review of an email provided by the VP of Quality dated 03/10/2015, from the local ambulance company revealed SP #1 was transported to the hospital, and documented according to the EMT (emergency medical technician) during transport, a member of the flight crew was on the phone with the hospital trying to solidify the admission because they were previously aware of an insurance issue. The email further documents this conversation was not successful, so upon arrival to the hospital, one member of the flight team went into the hospital in an attempt to get resolution. The email documented, our crew, the patient, other team member, and a family member stayed in the ambulance waiting for more solid information. They waited about one half hour to 45 minutes. During the wait, the family member got restless and wanted to know what was going on. Our driver took the family member into the hospital to meet up with the flight crew member. The email documented, when the flight crew came out, he directed our crew to take the patient to hospital #2 because he was being told that the patient's insurance would not cover the patient being admitted to the hospital. The patient was transported to hospital #2.


During interview on 03/18/15 at 1:30PM with the ER physician, revealed he worked for the patient's insurance company (name) He reported, that the insurance company provides insurance to business and cruise ship travelers. He stated, the insurance company makes the transfer arrangements for patients, including communication with hospital staff. He stated, Travel Guard had offices all over the world, including one in Houston, Texas. He stated that, this facility accepts everything. He stated, SP#1 lived in the United States and was probably on vacation on the Island of Anguilla. He stated, SP#1 was already accepted and the facility was waiting for confirmation of arrival time. However, before he left the facility, the Friday evening around twelve midnight, he called the insurance company's On-call, to get an estimated time of arrival for the patient. He stated, the insurance company told him that the patient was no longer coming to this facility and that the patient was going to another acute care hospital. He stated, he never got a call from the air ambulance staff regarding the patient's transfer. He stated, usually, the air ambulance calls and informs the Travel insurance company with an estimated time of arrival. He stated that the air ambulance did not communicate with the insurance company regarding the transfer, which was unusual. He stated, he was not in the ER when the ambulance staff arrived. He found out that the patient was outside in the ambulance, when he returned to the ER the following morning.

During interview on 03/18/15 at 2:08 PM, the nursing supervisor reported, before international patients are transferred to the facility she verifies the patient's insurance information and provides accep