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Based on review of medical records, Emergency Medical Services (EMS) Report, interviews and review of policy and procedures, the hospital failed to ensure that an appropriate medical screening examination was provided to an individual that was within the capability of the hospital's emergency department to determine whether or not an emergency medical condition existed for 1 (Patient #1) of 31 patients seeking medical care. Refer to findings at Tag A-2406

Based on reviews of medical records, policy and procedures, and EMS reports, and interviews, the hospital failed to ensure that an individual with an identified emergency medical condition was transferred appropriately by not knowing where the patient was going and not notifying the receiving hospital of the transfer for 1 (Patient #1) of 31 patients seeking medical care. Refer to findings at Tag A-2409.

Based on review of the facility's policy and procedures and records, the facility failed to maintain a medical and other related records related to individuals transferred to and from the hospital for 1 (Patient #1) of 31 sampled patients.

The findings included:

Record review of hospital policy titled "medical screenings and treatment of emergency medical conditions at SMH" dated 3/13 stated "all medical and other records related to screening examinations and treatment of patients shall be maintained for a period of five years from the screening date or treatment. Such records shall be included . . . as the permanent medical record of the patient."

Review of the ECC central log for 7/2/15 between 12:14 a.m. and 1:24 a.m. showed that Patient #1 was never registered in the facility ' s central log. Review of ECC occurrence report for left-without-being-seen logs for 7/2/15 between 12:14 a.m. and 1:24 a.m., showed the patient was never registered.

The facility failed to ensure that their policy and procedure was followed as evidenced by failing to provide evidence that a medical record was created for Patient #1 on 7/2/15 when she presented to the North Port Emergency Care Center seeking medical treatment.

Based on interviews and reviews of emergency medical services (EMS) reports, policy and procedures, and Emergency Care Center occurrence reports, the hospital failed to maintain a central log on each individual who comes to the emergency department seeking medical care for 1 (Patient #1) of 31 patients reviewed.

The findings included:

Sarasota Memorial Hospital (SMH) operates the North Port Emergency Care Center (ECC), an off-site emergency department in North Port, Florida. Record review of hospital policy titled "medical screenings and treatment of emergency medical conditions at SMH" dated 3/13 stated ". . . other records related to . . . treatment of patients shall be maintained for a period of five years from the screening date or treatment. Such records shall be included in a log as well as the permanent medical record of the patient."

Review of Patient #1's Patient Care Report from North Port EMS showed on 7/2/15 at 12:14 a.m., EMS was dispatched to a motor vehicle accident with a chief complaint of "traumatic injury not otherwise specified." The patient told EMS she was "25 weeks pregnant" and "she had pain to the left and right side of her abdomen and pain to her right upper leg." EMS contacted North Port ECC to notify them they would be coming shortly and the patient's status. When EMS arrived on the ECC property, Doctor A, met both EMS and Patient #1 in the ECC ambulance bay. The EMS documented Doctor A spoke with the patient and advised her they will only evaluate immediate life threats and then transfer her to an obstetrics (OB) hospital since she was pregnant. Doctor A told the patient "he would be happy to see her," "but it would probably be best to just go to another hospital right away." EMS documented the patient decided to go to a hospital with OB services located 8.5 miles away.

Review of the ECC central log for 7/2/15 between 12:14 a.m. and 1:24 a.m. showed that Patient #1 was never registered in the facility ' s central log. Review of ECC occurrence report for left-without-being-seen logs for 7/2/15 between 12:14 a.m. and 1:24 a.m., showed the patient was never registered.

In an interview on 8/11/15 at 1:25 p.m., the SMH Emergency Department Medical Director confirmed for Patient #1 the hospital "did not follow the correct procedure." He also said "no matter what the situation is" all patients arriving on hospital property must be registered.

In an interview on 8/11/15 at 2:00 p.m., Doctor A confirmed the 7/2/15 event for Patient #1. He confirmed the patient was never registered on the central log.

In an interview on 8/11/15 at 2:30 p.m., the SMH Risk Management Director confirmed the 7/2/15 event for Patient #1. She said the doctor did not follow the hospital's policy. She confirmed it has always been the hospital's policy to register all clients whom arrive at the hospital.

Based on review of medical records, Emergency Medical Services (EMS) Report, interviews and review of policy and procedures, the hospital failed to ensure that an appropriate medical screening examination was provided to an individual that was within the capability of the hospital's emergency department to determine whether or not an emergency medical condition existed for 1 (Patient #1) of 31 patients seeking medical care.


The findings included:

Sarasota Memorial Hospital (SMH) operates the North Port Emergency Care Center (ECC), an off-site emergency department in North Port, Florida.
Review of the hospital's policy titled "medical screenings and treatment of emergency medical conditions at SMH" dated 3/13 revealed "any patient who presents to SMH shall be provided with a medical screening examination to determine whether the patient is experiencing an emergency medical condition."

Review of Patient #1's Patient Care Report from North Port EMS showed on 7/2/15 at 12:14 a.m., EMS was dispatched to a motor vehicle accident with a chief complaint of "traumatic injury not otherwise specified." The patient told EMS she was "25 weeks pregnant" and "she had pain to the left and right side of her abdomen and pain to her right upper leg." EMS contacted the North Port ECC to notify them they would be coming shortly and the patient's status. When EMS arrived on the ECC's property, Doctor A, met both EMS and Patient #1 in the ECC ambulance bay. EMS documented Doctor A spoke with the patient and advised her they will only evaluate immediate life threats and then transfer her to an obstetric (OB) hospital since she was pregnant. Doctor A told the patient "he would be happy to see her," "but it would probably be best to just go to another hospital right away." EMS documented the patient decided to go to a hospital with OB services located 8.5 miles away.

Review of the receiving hospital's medical records showed the patient arrived on 7/2/15 at 1:24 a.m. The physical examination from the receiving hospital revealed in part, " ... Abdomen: Non tender to superficial or deep palpitation. Uterus of 25 weeks gestational size palpable. Fetal Heart tones present at 120 per minute ... Conclusion 1. Pregnancy at 25 weeks 3 days gestation. 2. The patient involved in car accident. 3. Rule out placenta abruption. Plan: Obstetric ultrasound to rule our placenta abruption and electronic fetal monitoring. " Patient #1 was transferred to the maternity ward for further evaluation.

In an interview on 8/11/15 at 1:25 p.m., the SMH Emergency Department Medical Director confirmed the hospital "did not follow the correct procedure" for Patient #1 on 7/2/15. He said "no matter what the situation is" all patients arriving on the hospital's property must be registered and a medical screening must always be done before any transfers. The SMH Emergency Department Director also stated that, basically this facility would provide for the mom- anything from 18-20 weeks- all patients are referred to the obstetrical unit for fetal monitoring.

In an interview on 8/11/15 at 1:35 p.m., Nurse A confirmed the 7/2/15 event for Patient #1. She said Doctor A did not think they could handle the patient's needs, but she told them they have to see the patient. She went and set up the fetal monitor and prepped the room for patient arrival. When she returned to the desk, the "physician told me the patient already left the ambulance bay with EMS and went to a higher level of care." She confirmed the patient was not given an appropriate medical screening.

In an interview on 8/11/15 at 2:00 p.m., Doctor A confirmed the 7/2/15 event for Patient #1. He said he met the patient in the ambulance bay and discussed the event. He said he "did not know what hospital the patient would go to when they left," and he "left it up to EMS to decide." He confirmed the patient was not given an appropriate medical screening.

In an interview on 8/11/15 at 2:30 p.m., the SMH Risk Management Director confirmed the 7/2/15 event for Patient #1. She said the doctor did not follow the hospital's policy. She confirmed the patient was not given an appropriate medical screening. The Risk Manager also confirmed the doctor did not follow the hospital's policy and the ECC does have the capability to perform ultrasound and fetal heart tones on pregnant patients

In an interview on 8/12/15 at 2:15 p.m., Patient #1 said the evening "was a very confusing night." She said Doctor A met her in the ambulance bay and told her "if anything went wrong she would need to be transferred, which could cause delays in the treatment of the baby." She further stated that she did not want to hurt the baby and since it did not appear he wanted to look at her, she decided to go to another hospital.

Based on reviews of medical records, policy and procedures, and EMS reports, and interviews, the hospital failed to ensure that an individual with an identified emergency medical condition was transferred appropriately by not knowing where the patient was going and not notifying the receiving hospital of the transfer for 1 (Patient #1) of 31 patients seeking medical care. See tag A-2406 for additional information regarding Patient #1.

The findings included:

Review of hospital's policy titled "transfer of patients to and from SMH" revealed "it is the policy of SMH to facilitate transfers to and from the hospital in accordance with state and federal laws and regulations ... Transfers from the Emergency Care Center (ECC): Emergency medical condition-appropriate transfers: in cases of transfer from SMH, the following procedures will apply: in all other cases of transfers from SMH, a transfer may be arranged and affected using the following procedures to the extent deemed appropriate under the circumstances. 1. The patient will be provided with medical treatment within the capacity of SMH to minimize the risks to the patient ' s health ... 2. The responsible physician will contact the most appropriate receiving facility and obtain verbal confirmation regarding the following information: a. Designated ECC staff will contact and confirm that the receiving facility agrees to accept the transfer and to provide appropriate medical treatment; and b. The responsible physician will contact the physician at the receiving facility and confirm that the physician at the receiving facility has in fact agreed to accept the transfer. The name and position of the accepting physician will be recorded in the medial record. 3. The responsible physician will determine the appropriate level of care to be provided during the transport... 5. Emergency room personnel from the sending and receiving facility will coordinate the transfer ... 6. Copies of the following documents will be sent to the receiving facility with the patient: a. all medical records available at the time of transfer relating to the condition for which the patient has presented, including any records relating to the patient ' s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, treatment provided and the results of any tests including but not limited to: nursing notes, vital signs, dictation. MARs [medication administration records], labs, radiology results with CD images, written consents if any, transfer forms, if any. "

Patient #1's Patient Care Report from North Port EMS dated 7/2/2015 was reviewed. The report revealed in part, care revealed in part, when EMS arrived on the ECC property, Doctor A, met both EMS and Patient #1 in the ECC ambulance bay. EMS documented Doctor A spoke with the patient and advised her they will only evaluate immediate life threats and then transfer her to an obstetric (OB) hospital since she was pregnant. Doctor A told the patient "he would be happy to see her," "but it would probably be best to just go to another hospital right away." EMS documented the patient decided to go to a hospital with OB services located 8.5 miles away.

An interview was conducted with the Risk Manager Clinician A on 8/11/2011 at 11:30 a.m. The clinician stated that a pregnant patient (Patient #1) was seen in the emergency room (ER) bay and the medical doctor approached the patient in the ambulance and did not fill out paperwork but transferred the patient to the a receiving hospital . She also stated that the receiving facility notified them which was how they found out about this issue. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure the ER physician contact the physician at the receiving facility and confirm that the physician at the receiving facility had agreed to accept the transfer. The facility failed to complete a written certification of transfer for Patient #1 on 7/2/2015.
In an interview on 8/11/15 at 1:25 p.m., SMH Emergency Department Medical Director confirmed the hospital "did not follow the correct procedure" on 7/2/15. He said "no matter what the situation is" all patients arriving on the hospital's property must be registered and a medical screening must always be done before any transfers.

In an interview on 8/11/15 at 1:35 p.m., Nurse A confirmed the 7/2/15 event for Patient #1. She confirmed the receiving hospital was not called or notified of the transfer.

In an interview on 8/11/15 at 2:00 p.m., Doctor A confirmed he met Patient #1 in the ambulance bay and discussed the event. He said he "did not know what hospital the patient would go to when they left" and he "left it up to EMS to decide." He confirmed since the discussion of where to go was left up to the patient and EMS. He confirmed the receiving hospital was not called or notified of the transfer.

In an interview on 8/11/15 at 2:30 p.m., the SMH Risk Management Director confirmed the doctor did not follow the hospital's policy. She confirmed the hospital was not aware of the event until the receiving hospital reported it to them on 7/2/15. She confirmed the ECC Clinical Manager became aware of the issue by EMS on 7/4/15. The Risk Management Director also confirmed the receiving hospital was not called or notified of the transfer.

In an interview on 8/12/15 at 2:15 p.m., Patient #1 said the evening "was a very confusing night." She said Doctor A met her in the ambulance bay and told her "if anything went wrong she would need to be transferred, which could cause delays in the treatment of the baby." She said Doctor A told her to go to either SMH or a receiving hospital where they had OB services and then closed the door on the ambulance. The ambulance driver then told her the closest hospital was the receiving hospital and she agreed to go there.