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.

CLEVELAND CLINIC MARTIN NORTH HOSPITAL 200 SE HOSPITAL AVE STUART, FL 34995 March 2, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on facility policy and clinical record reviews and interviews the facility failed to provide evidence of an appropriate transfer to include documentation of the provision of treatment to minimize risk of deterioration, written physician certification of the risk and benefit of transfer and contact with and acceptance of the patient by the receiving facility for 1 of 26 sampled patients (Patient # 26). Refer to findings in tag A-2409.
VIOLATION: HOSPITAL MUST MAINTAIN RECORDS Tag No: A2403
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on reviews of medical records and policy and procedures and interviews the facility failed to ensure medical records and other related records were maintained for 1 of 26 sampled patients (Patient # 26) that presented to the hospital seeking medical assistance.


The findings include:

The facility ' s policy titled " Martin Medical Center ...Department of Nursing " Reviewed/Revised 10/13, revealed in part, " Procedure: To ensure continuity and consistency in Nursing Documentation for permanent patient record. Standard: Every patient evaluated and treated in the Emergency Department will have computerized nursing documentation which includes triage assessment, vital signs, medication, allergies treatments and discharge assessment ... triage Nurse ...An initial triage assessment will be made including chief complaint ...Primary Nurse: Ascertain information regarding history of illness or injury and add pertinent information to medical record. "


The medical record for Patient #26 dated 2/7/2015 obtained from facility B (an acute care hospital/trauma center) was reviewed on 2/27/2015. Review of the medical record indicated in part " [AGE] year-old (Pt #26) presents emergency department, via trauma hawk. Per paramedic patient was picked up outside at Martin hospital ... by boyfriend, allegedly patient jumped out of a moving vehicle. Sustained closed head injury. Patient intubated in the field by paramedics. "

Interview with The Director of The Emergency Department (ED) conducted on 02/27/15 at 11:30 AM confirms Patient # 26 did not have a medical record at the facility.

Phone interview with The Clinical Coordinator conducted on 02/27/15 at 12:03 PM revealed her recollection of an incident on 02/06/15 as, Patient (#26) was brought to the ED by her boyfriend; the patient's vehicle was parked at the ambulance bay and the boyfriend came in requesting help for the patient. The staff including a physician and herself went went out to help. The nurse confirmed no medical record was created for Patient # 26. The facility failed to ensure that their policy was followed as evidenced by failing to ensure that on 2/7/2015 a medical record was maintained for Patient #26 when he/she presented to the ED .
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on review of the Emergency Department (ED) Log and interview the hospital failed to maintain a central log on each individual who comes to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 (#26) of 26 sampled patients.
The findings include:
Review of the ED Log dated 2/1/2015 through 2/13/2015 revealed no documentation that Patient #26 was entered in the ED log. Interview with the Director of the Emergency Department conducted on 02/27/2015 at 11:30 A.M., confirmed Patient #26 was not listed on the emergency room log on 2/7/2015.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on facility policy and clinical record reviews and interviews the facility failed to provide evidence of an appropriate transfer to include documentation of the provision of treatment to minimize risk of deterioration, written physician certification of the risk and benefit of transfer and contact with and acceptance of the patient by the receiving facility for 1 of 26 sampled patients (Patient # 26).


The findings include:


Review on 2/27/15 of the clinical records obtained from facility B (an acute care hospital/trauma center) dated 02/06/15 indicates Patient # 26 presented to the Martin Medical Center emergency department (ED) and emergency services were requested on her behalf. Patient # 26 was subsequently transferred to facility B.

Interview with The Director of the Emergency Department (ED) conducted on 02/27/15 at 11:30 AM revealed the facility was unable to provide any supportive evidence verifying compliance with the transfer requirement at 489 (e) (2). A transfer to another medical facility is appropriate when the transferring facility provides treatment to minimize risk of deterioration; the receiving facility has available space and qualified personal to treat the patient being transferred; the receiving facility has agreed to receive the transfer and provide medical treatment and the transferring facility sends to the receiving facility all medical records. Refer to citation A 2403 in this report. Furthermore, the facility protocol to be followed to execute a transfer was not implemented.

Phone interview with The Physician, who was on duty the night of the incident, conducted on 02/27/15 at 12:39 PM revealed Patient # 26 presented to the facility after falling form a moving vehicle; The EMS (emergency medical system) personnel was called to assist in removing the patient from the vehicle, the patient was argumentative and intoxicated. EMS made the decision to transfer the patient to the trauma center based on the patient's injuries. The EMS has protocols to follow when trauma cases occurred and they assumed care of the patient. The physician was not able to provide supportive evidence for an appropriate transfer and did not recall if the receiving facility was contacted prior to the transfer.

Interview with The ED Medical Director conducted on 03/02/15 at 12 PM revealed the patient presented on hospital property. He stated the cleanest way to handle this situation would have been to document the screening exam, stabilization of the patient and contacting the receiving facility to advise the patient was being transferred; all these steps may have delayed the transfer, but that is the facility protocol.

The facility was not able to provide evidence the physician has signed a certification or other documentation that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual from being transferred. There is no certification by the physician or qualified medical professional containing a summary of the risks and benefits upon which it is based. The facility has no evidence the receiving facility received pertinent medical records related to the emergency condition which the individual has presented with that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification.


Facility policy for Emergent Transfer of Patients To An Acute Care Facility documents The Emergency Physician initiates transfers for patients requiring services that are not provided or available. Discusses transfers with patient/family and obtains consent. Writes transfer orders and notifies transfer center. Complete and signs physician certification: In electronic medical record under EMTALA transfer Documentation in section 1: Physician Certification. Notifies nursing supervisor prior to contacting receiving facilities.
The transfer center, charge nurse or nursing supervisor initiates the call to potential receiving facilities using call log list. Documents all calls listing reasons given for declining the transfer.
The charge nurse, transfer center and nursing supervisor prepares and reviews consent forms; arrange appropriate transportation; completes inter hospital transfer summary and nurse certification from the electronic record and send as copy to the receiving facility.