The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HOLMES REGIONAL MEDICAL CENTER 1350 S HICKORY ST MELBOURNE, FL 32901 Oct. 21, 2011
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interview and record review, the hospital failed to ensure compliance with special responsibilities of Medicare hospitals in emergency cases.

Findings:


1. Cross Refer A2402. Based on observation and interview, the facility failed to ensure the conspicuous posting in the emergency department as well as the labor & delivery area a sign specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor.

2. Cross Refer A2405. Based on interview, record review and a review of facility documentation in the form of filmed footage, the facility failed to ensure the maintenance of an accurate central log with respect to presentation times on each individual who comes to the Emergency Department in one of twenty-four sampled patients (#1).

3. Cross Refer A2406. Based on interview, record review and a review of facility documentation in the form of filmed footage, the facility failed to ensure the provision of a medical screening examination at the time a patient first came to the emergency department in one of twenty-four sampled patients (#1).

4. Cross Refer A2407. Based on interview, record review and a review of facility documentation in the form of filmed footage, the facility failed to ensure the provision of stabilizing treatment at the time a patient first came to the emergency department in one of twenty-four sampled patients (#1).
VIOLATION: POSTING OF SIGNS Tag No: A2402
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on observation and interview, the facility failed to ensure the conspicuous posting in the emergency department as well as the labor & delivery area a sign specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor.

Findings:

During a tour of the emergency room on [DATE] at 10:25 AM, it was observed that there was no posting of a sign specifying the rights of individuals with respect to examination and treatment for emergency medical conditions and women and labor. In addition, a tour of the Labor & Delivery Department at 10:40 AM revealed that it had a main lobby entrance and a back entrance on the fourth floor. Both entrances were arranged whereby a non-employee seeking entrance would need to gain approval from security. The back entrance had no signage of the type described above anywhere in close proximity. During interviews of the emergency room Manager at the above stated tour times, he confirmed the preceding.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and a review of facility documentation in the form of filmed footage, the facility failed to ensure the maintenance of an accurate central log with respect to presentation times on each individual who comes to the Emergency Department in one of twenty-four sampled patients (#1).


Findings:

An interview conducted with the Director of Emergency Services (along with the Director Quality and Risk Manager) on 10/21/11 at 1:19 PM revealed the following information regarding the presentation of #1 and her husband to the facility on [DATE]. She stated that the patient's husband drove up to the emergency room door. The husband then came in and told a Registered Nurse that his wife was pregnant, in the car outside, and having complications. He stated that she was 7 ? months pregnant. The nurse told the husband that since she was 7 ? months pregnant, she needed to go to labor and delivery. The nurse then gave the husband directions on how to get there. The Director of Emergency Services stated during the interview that Labor & Delivery was on the opposite side of the building. The husband left the emergency room , went out to his car and drove around the building. Next, he drove up to the outpatient entrance which is directly across from the Labor & Delivery entrance by approximately 40 feet. He then left the car and went into the Outpatient entrance seeking help. After some delay, the patient was brought into the hospital by a Code team, which took her to the emergency room .

A review of video of the preceding was performed on 10/21/11 at approximately 2:00 PM. The video had time signatures. The following events took place at the approximate stated times:
12:09:40 Car arrives in ER driveway
12:09:52 The husband is at the ER reception desk. At this time he engages in a discussion with the RN, with the paramedic watching.
12:10:29 The husband leaves the nurse.
12:10:42 The patient drives away
12:12:19 The husband arrives at the Outpatient driveway.
12:12:45 The husband is out of the car.
12:13:05 The Registration Clerk and volunteer head out to the car.
12:13:43 The Registration Clerk and the Volunteer are back inside.
12:13:54 The volunteer is out to the car.
12:14:00. The volunteer is back in.
12:15:13 The volunteer leaves
12:15:48 The EKG tech goes out to the car
12:16:00 The supervisor is seen waiting for the code responders
12:16:37 The Code team arrives.
12:17:25 #1 is placed on a gurney.
12:17:58 A code cart is observed.
12:18:22 The patient is brought into the hospital.

The preceding findings from video were generally consistent with the findings from the interview with the Director of Emergency Department as mentioned above.

A review of the emergency room log was performed. It revealed a presentation of #1 to the emergency room at 12:31 PM. Per the above interview of the Emergency Department Director at the above stated time, the time of initial presentation of #1 to the emergency room was prior to this log report of 12:31 PM. The 12:31 PM time was after the patient had arrived at the entrance to Labor & Delivery, on the other side of the building. This constitutes an inaccurate emergency room log.

The preceding findings were confirmed during an interview of the Risk Manager, Quality Director and Emergency Department Director at approximately 5:15 PM on 10/21/11.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and a review of facility documentation in the form of filmed footage, the facility failed to ensure the provision of a medical screening examination at the time a patient first came to the emergency department in one of twenty-four sampled patients (#1).

Findings:

Facility policy "Care of the Emergency Department Patient" was reviewed. It read: "Patients presenting to the Emergency Department will be assessed by a Registered Nurse and triaged in order to initiate medical screening and treatment". A review of Medical Staff Bylaws revealed the following: "Screening examinations and stabilization for all patients in the Emergency Department will be performed by either a Physician on the Active or Provisional Medical Staff under the direct supervision of a Medical Staff physician."

An interview conducted with the Director of Emergency Services (along with the Director Quality and Risk Manager) on 10/21/11 at 1:19 PM revealed the following information regarding the presentation of #1 and her husband to the facility on [DATE]. She stated that the patient's husband drove up to the emergency room door. The husband then came in and told a Registered Nurse that his wife was pregnant, in the car outside, and having complications. He stated that she was 7 ? months pregnant. The nurse told the husband that since she was 7 ? months pregnant, she needed to go to labor and delivery. The nurse then gave the husband directions on how to get there. The Director of Emergency Services stated during the interview that Labor & Delivery was on the opposite side of the building. The husband left the emergency room , went out to his car and drove around the building. Next, he drove up to the outpatient entrance which is directly across from the Labor & Delivery entrance by approximately 40 feet. He then left the car and went into the Outpatient entrance seeking help. After some delay, the patient was brought into the hospital by a Code team, which took her to the emergency room .

A review of video of the preceding was performed on 10/21/11 at approximately 2:00 PM. The video had time signatures. The findings from video were generally consistent with the findings from the interview with the Director of Emergency Department as mentioned above.

A review of the medical record of #1 was performed. There was no documentation in the medical record of the patient's initial presentation to the emergency room as discussed in the interview, above. Since an effort was not extended by emergency room staff in the first presentation to bring the patient into the emergency room , and the patient's family member was instead directed to drive in their own vehicle to the other side of the building, removing them from any continuity of care by the facility, the facility denied the patient a medical screening examination.

The preceding findings were confirmed during an interview of the Risk Manager, Quality Director and Emergency Department Director at approximately 5:15 PM on 10/21/11.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and a review of facility documentation in the form of filmed footage, the facility failed to ensure the provision of stabilizing treatment at the time a patient first came to the emergency department in one of twenty-four sampled patients (#1).

Findings:

Facility policy "Care of the Emergency Department Patient" was reviewed. It read: "Patients presenting to the Emergency Department will be assessed by a Registered Nurse and triaged in order to initiate medical screening and treatment." A review of Medical Staff Bylaws revealed the following: "Screening examinations and stabilization for all patients in the Emergency Department will be performed by either a Physician on the Active or Provisional Medical Staff under the direct supervision of a Medical Staff physician."

An interview conducted with the Director of Emergency Services (along with the Director Quality and Risk Manager) on 10/21/11 at 1:19 PM revealed the following information regarding the presentation of #1 and her husband to the facility on [DATE]. She stated that the patient's husband drove up to the emergency room door. The husband then came in and told a Registered Nurse that his wife was pregnant, in the car outside, and having complications. He stated that she was 7 ? months pregnant. The nurse told the husband that since she was 7 ? months pregnant, she needed to go to labor and delivery. The nurse then gave the husband directions on how to get there. The Director of Emergency Services stated during the interview that Labor & Delivery was on the opposite side of the building. The husband left the emergency room , went out to his car and drove around the building. Next, he drove up to the outpatient entrance which is directly across from the Labor & Delivery entrance by approximately 40 feet. He then left the car and went into the Outpatient entrance seeking help. After some delay, the patient was brought into the hospital by a Code team, which took her to the emergency room .

A review of video of the preceding was performed on 10/21/11 at approximately 2:00 PM. The video had time signatures. The findings from video were generally consistent with the findings from the interview with the Director of Emergency Department as mentioned above.

A review of the medical record of #1 was performed. There was no documentation in the medical record of the patient's initial presentation to the emergency room as discussed in the interview, above. Since an effort was not extended by emergency room staff in the first presentation to bring the patient into the emergency room , and the patient's family member was instead directed to drive in their own vehicle to the other side of the building, removing them from any continuity of care by the facility, the facility denied the patient stabilizing treatment.

The preceding findings were confirmed during an interview of the Risk Manager, Quality Director and Emergency Department Director at approximately 5:15 PM on 10/21/11.