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.

TWIN CITIES HOSPITAL 2190 HWY 85 N NICEVILLE, FL 32578 Feb. 3, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of written Emergency Medical Service (EMS) staff statements, Twin Cities Hospital written self-report of violation, review of Emergency Department policy and procedures, and interviews with the hospital Chief Executive Officer (CEO), Quality/ Risk Manager, Emergency Department (ED) Director, and other ED staff members, it was determined the hospital failed follow established Policy and Procedures for the Emergency Medical Treatment and Labor Act (EMTALA) by failing to provide a Medical Screening Exam (MSE), Stabilizing Treatment, and Appropriate Transfer to another hospital for 1 of 21 patients in the sample (#21).

The facility self-reported the EMTALA violation, and developed and implemented a corrective action plan to address the violation.

The findings are:
The hospital provided a copy of their policy entitled "EMATLA - Definitions and General Requirements", dated 3/2/2013, and approved by the Ethics and Compliance Policy Committee. The policy states, (in part):
"A. General Requirements: Any hospital with an emergency department will provide to any individual who "comes to the emergency department" an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an EMC exists, regardless of the individual's ability to pay when a request is made by or on behalf of the individual for medical care, or a prudent layperson would observe that such care is needed, whether the individual is in the hospital's dedicated emergency department (DED) or elsewhere on the hospital's campus. EMTALA requires the hospital to do the following:
1. Provide an appropriate MSE to the individual within the capability of the hospital's emergency department to determine whether or not an EMC (emergency medical condition) exists."

The facility also provided a copy of their ED specific "EMTALA Florida Medical Screening Examination and Stabilizing Policy", dated last approved in 12/2014. The policy includes the following:
"An EMTALA obligation is triggered when an individual comes to a dedicated emergency department and: the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition, or a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition.

When an MSE is Required: A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists. An MSE shall be provided to determine whether or not the individual is experiencing an EMC or a pregnant woman is in labor. An MSE is required when: The individual comes to a dedicated emergency department of a hospital and a request is made by
the individual or on the individual's behalf for examination or treatment for a medical condition,
including where:
i. The individual requests medication to resolve or provide stabilizing treatment for a medical
condition.
ii. The individual arrives as a transfer from another hospital or health care facility. Upon arrival of a transfer, a physician or qualified medical person ("QMP") must perform an appropriate MSE.
The Physician or QMP shall provide any additional screening and treatment required to stabilize
the EMC. The MSE of the individual must be documented. This type of screening cannot be
performed by the triage nurse. If an emergency medical condition is determined to exist and the
hospital admits the individual as an inpatient for further treatment, the hospital's obligation under
EMTALA ceases.

Caution: If the ambulance staff disregards the hospital's instructions and brings the individual
on to hospital property, the individual has come to the emergency department and the hospital
must perform an appropriate MSE. Should a hospital which is not in official diversionary status
fail to accept a telephone or radio request for transfer or admission, the refusal could represent
a violation of other Federal or State regulations.

A written statement dated 1/3/15 was provided by the EMS (emergency medical services) paramedic who was in the ambulance with a patient being taken to the hospital ED. The statement is summarized as follows: On 1/3/15 at an undetermined time between 11:00 pm and 11:39 pm EMS contacted the hospital by radio to report they were bringing an unstable patient in respiratory distress, with brain cancer, and a valid Do Not Resuscitate Order (DNR) to the hospital. Before the EMS Paramedic "realized it", the ambulance was already on hospital property and pulling under the emergency room door's canopy. In the written statement provided by the Paramedic he states at that time a female instructed him over the radio that per the ED Physician, they were to divert to the areas military hospital. The Paramedic reports in his statement that he responded to the female that "we were on their property with an unstable patient. I asked if they still wanted EMS to divert. The response was "yes, take the patient to (name of military hospital)." The Paramedic reported in his statement that while the ambulance was stopped under the hospital ED canopy a nurse walked out to the ambulance and made contact with his partner who was in the driver seat. The Paramedic states he could not hear their conversation, but he stuck his head through the bulkhead and asked his partner to tell the nurse they were about to commit an EMTALA violation. The Paramedic states he heard his partner tell the nurse this was against the law. He states they then diverted to the military hospital.

An interview was conducted on 2/2/15 at approximately 2:50 p.m. The Quality/ Risk manager (QRM) played 2 digital recordings from the EMS communication log. She stated these recordings were provided by the EMS dispatch, at the request of the hospital. The first recording was from the initial report given to the ED by EMS regarding the patient/ history and assessment. The charge nurse from the ED was speaking with the paramedic in the ambulance, on the radio. The paramedic reported the patient with oxygen saturation of 78%, history of terminal brain cancer, has a DNR (Do Not Resuscitate order), had vomited earlier in the evening, and was now with difficulty breathing. The paramedic did state that he was unsure if the patient had aspirated. He did state the lung sounds indicated congestion. The nurse informed him the patient needed to go to (name of a military hospital). The hospital account of the incident indicates the charge nurse had received a telephone report from a nurse at the sending nursing home facility regarding the patient. The nurse relayed the information from the nursing home report to the physician on duty in the ED. The physician then called the EMS dispatch to inform them that the ED was operating over capacity ("patients are stacked up like cord-wood"). This conversation was also recorded, and listened to. The physician stated that the hospital had no neurosurgery or pulmonologist capability and the ER was over capacity at that time. He informed EMS dispatch that the patient should go to local military hospital, as the family had requested that (per nursing report from the hospital), and he was currently receiving treatment from the military hospital for his brain cancer. By the time the conversation was over, EMS announced by radio that they were already on the hospital property. This communication was transmitted very soon after the initial EMS report was given via radio. The QRM was asked what times were recorded for both of these recorded communications, and she stated that the times were not provided by EMS dispatch.

A telephone interview was conducted on 2/3/15 at approximately 7:15 p.m. with ED staff nurse "E"., who was on shift in the ED on the night of 1/3/15: The nurse stated the nursing home had called and told them about a patient being transported by EMS to our ED because he was having breathing problems, and that he had brain cancer, and was a DNR, and the patient's family had wanted him to be taken to (name of military hospital) because that was where he was receiving the cancer treatment. EMS stated they were going to take the patient to the nearest hospital, which was our ED. It was a very busy shift, and all beds in the ED were full. She heard the ED physician say to get the EMS dispatch on the line because the patient should probably go to (name of military hospital) because the beds were full in the ED, and they have no on-call neurosurgeon or pulmonologist. At the time the physician was on the phone with EMS dispatch, the ambulance called on the radio to give report on the patient. The nurse could not hear all of the report because the nurse speaking on the radio kept keying the microphone while the paramedic was giving report, and that cut out his voice. She told the nurse taking report several times to stop keying the microphone because the paramedic couldn't hear her, and they couldn't hear report. The nurse taking report was trying to tell EMS to divert to the military hospital and EMS stated they were on hospital property. Just a moment later, they pulled up in the ambulance bay. A (respiratory therapist, staff "F") asked what she should tell them, and the nurse taking report told her to send them to the military hospital. Staff "E" claims to have stated "that is going to be an EMTALA violation". The ED Physician was still on the phone with EMS dispatch, and once he was informed the ambulance was on the property and in the bay, he terminated his call but the ambulance had already left the bay headed to (name of the military hospital). Staff "E" stated she then went and notified the House Supervisor of the EMTALA violation, and explained the circumstances to her.

A telephone interview was conducted on 2/3/15 at approximately 8:00 p.m. with staff "F", who was in the ED during the incident on 1/3/15. She stated that the entire incident occurred over the time span of only a couple of minutes. She states that when EMS reported they were on the property, she went to the bay and looked outside and saw them approaching. She asked the charge nurse what to tell them, and she said to send them to the military hospital. She went outside and the ambulance rolled up. She spoke with the driver through the window and told them they want you to go to the military hospital. The driver made a comment about "breaking the law" and drove off. She states she was just trying to help speed up whatever was going to happen as they were very busy and all beds were full, and her only intent was to relay information and not to provide guidance or make any decisions.

The emergency department physician on duty at the time of the incident (staff "K") is unavailable for interview and currently out of the state.

Time line for ED census on 1/3/15 was provided by the Chief Executive Officer (CEO). The ED census prior to and at the time of the incident was as follows (the incident occurred between 10:47 pm and 11:39 pm on 1/3/15):
7:00pm-8:00pm: 15
8:00pm-9:00pm: 19
9:00pm-10:00pm: 17
10:00pm-11:00pm: 9
11:00pm-12:00am: 10

Twenty ED medical records were reviewed. All 20 medical records reviewed were found to appropriately reflect compliance with EMTALA requirements for a Medical Screening Exam, identification of an Emergency Medical Condition, stabilizing treatment, and appropriate transfer, when a transfer was determined to be necessary. There was no medical record for the patient who was transferred inappropriately (#21) because the patient was never brought into the ED at the hospital.

On 2/2/15 at approximately 12:10 p.m. a visit was made to the nursing home who sent the patient to the hospital ED. The nursing home Administrator provided a copy of the face sheet and nursing assessment notes leading up to the decision to send the patient out to the hospital. A review of the nursing notes revealed that the patient was transported to the hospital by EMS at around 11:20 p.m. on 1/3/15.

A review of the written statement provided by the EMS staff who was on the ambulance run has documentation only that the ambulance was dispatched on 1/3/15 at 10:47 p.m. to the nursing home, and arrived at 11:39, at the military hospital.

An interview was conducted with the hospital CEO (chief executive officer) on 2/3/15 at approximately 4:00 p.m. The CEO stated it was obvious that the charge nurse in the ED on 1/3/15, was responsible for EMS being turned away from the hospital and the hospital not providing the required MSE and stabilizing treatment. He stated that even though the ED was at capacity, and even though the hospital had no pulmonologist or neurosurgeon to treat the patient, they still had a responsibility to follow EMTALA requirements, and in this case that was not done. He stated that he views it as an isolated event. He reviewed the plan of correction and pointed out that the plan of correction has been fully implemented pending only the results of the Peer Review which will be completed when the ED physician on duty at the time of the event returns from vacation next week.

The survey was triggered based upon the hospital self-reporting the emergency access violation to the State of Florida Survey Agency. The self report included details of the event, and the hospital's plan of correction to ensure this type of incident will not occur in the future. The plan of correction includes the following:

1. The actions of the ED physician have been reported to the Peer Review Committee for review in accordance with the hospital Bylaws.
2. The CEO and ED Director will review and reevaluate the Hospital Diversion Policy, specifically the formula/process for determining criteria for over crowding.
3. Upon completion of the Diversion Policy review, education to the ED staff, ED Physicians and administrative supervisors on the appropriate procedures for implementing diversion status in the ED will be provided.
4. The Chief Nursing Officer (CNO) and ED Director completed an evaluation of the staffing patterns in the ED to ensure appropriate staffing during high volume time on 1/6/15.
5. The Respiratory Therapist who spoke with EMS was counseled regarding State Emergency Access laws and EMTALA Requirements.
6. ED, Respiratory Therapy, Security personnel, and all ED Physicians are currently receiving education regarding Florida's Emergency Access Laws and EMTALA requirements with all education to be completed no later than 1/31/15.

The review of the plan of correction revealed all corrective action has been completed as stated in the plan of correction with the exception of the verification of the completion of the Peer Review of the ED physician, at the time of the survey.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of written Emergency Medical Service (EMS) staff statements, Twin Cities Hospital written self-report of violation, review of Emergency Department policy and procedures, and interviews with the hospital Chief Executive Officer (CEO), Quality/Risk Manager, Emergency Department (ED) Director, and other ED staff members, the hospital failed to provide a Medical Screening Exam (MSE) for 1 of 21 patients in the sample (#21).

The findings are:

A written statement dated 1/3/15 was provided by the EMS (emergency medical services) paramedic who was in the ambulance with a patient being taken to the hospital ED. The statement is summarized as follows: On 1/3/15 at an undetermined time between 11:00 pm and 11:39 pm EMS contacted the hospital by radio to report they were bringing an unstable patient in respiratory distress, with brain cancer, and a valid Do Not Resuscitate Order (DNR) to the hospital. Before the EMS Paramedic "realized it", the ambulance was already on hospital property and pulling under the emergency room door's canopy. In the written statement provided by the Paramedic he states at that time a female instructed him over the radio that per the ED Physician, they were to divert to the areas military hospital. The Paramedic reports in his statement that he responded to the female that "we were on their property with an unstable patient. I asked if they still wanted EMS to divert. The response was "yes, take the patient to (name of military hospital)." The Paramedic reported in his statement that while the ambulance was stopped under the hospital ED canopy a nurse walked out to the ambulance and made contact with his partner who was in the driver seat. The Paramedic states he could not hear their conversation, but he stuck his head through the bulkhead and asked his partner to tell the nurse they were about to commit an EMTALA (Emergency Medical Treatment and Labor Act) violation. The Paramedic states he heard his partner tell the nurse this was against the law. He states they then diverted to the military hospital.

An interview was conducted on 2/2/15 at approximately 2:50 p.m. The Quality/ Risk manager (QRM) played 2 digital recordings from the EMS communication log. She stated these recordings were provided by the EMS dispatch, at the request of the hospital. The first recording was from the initial report given to the ED by EMS regarding the patient/ history and assessment. The charge nurse from the ED was speaking with the paramedic in the ambulance, on the radio. The paramedic reported the patient with oxygen saturation of 78%, history of terminal brain cancer, has a DNR (Do Not Resuscitate order), had vomited earlier in the evening, and was now with difficulty breathing. The paramedic did state that he was unsure if the patient had aspirated. He did state the lung sounds indicated congestion. The nurse informed him the patient needed to go to (name of a military hospital). The hospital account of the incident indicates the charge nurse had received a telephone report from a nurse at the sending nursing home facility regarding the patient. The nurse relayed the information from the nursing home report to the physician on duty in the ED. The physician then called the EMS dispatch to inform them that the ED was operating over capacity ("patients are stacked up like cord-wood"). This conversation was also recorded, and listened to. The physician stated that the hospital had no neurosurgery or pulmonologist capability and the ER was over capacity at that time. He informed EMS dispatch that the patient should go to local military hospital, as the family had requested that (per nursing report from the hospital), and he was currently receiving treatment from the military hospital for his brain cancer. By the time the conversation was over, EMS announced by radio that they were already on the hospital property. This communication was transmitted very soon after the initial EMS report was given via radio. The QRM was asked what times were recorded for both of these recorded communications, and she stated that the times were not provided by EMS dispatch.

A telephone interview was conducted on 2/3/15 at approximately 7:15 p.m. with ED staff nurse "E"., who was on shift in the ED on the night of 1/3/15: The nurse stated the nursing home had called and told them about a patient being transported by EMS to our ED because he was having breathing problems, and that he had brain cancer, and was a DNR, and the patient's family had wanted him to be taken to (name of military hospital) because that was where he was receiving the cancer treatment. EMS stated they were going to take the patient to the nearest hospital, which was our ED. It was a very busy shift, and all beds in the ED were full. She heard the ED physician say to get the EMS dispatch on the line because the patient should probably go to (name of military hospital) because the beds were full in the ED, and they have no on-call neurosurgeon or pulmonologist. At the time the physician was on the phone with EMS dispatch, the ambulance called on the radio to give report on the patient. The nurse could not hear all of the report because the nurse speaking on the radio kept keying the microphone while the paramedic was giving report, and that cut out his voice. She told the nurse taking report several times to stop keying the microphone because the paramedic couldn't hear her, and they couldn't hear report. The nurse taking report was trying to tell EMS to divert to the military hospital and EMS stated they were on hospital property. Just a moment later, they pulled up in the ambulance bay. A (respiratory therapist, staff "F") asked what she should tell them, and the nurse taking report told her to send them to the military hospital. Staff "E" claims to have stated "that is going to be an EMTALA violation". The ED Physician was still on the phone with EMS dispatch, and once he was informed the ambulance was on the property and in the bay, he terminated his call but the ambulance had already left the bay headed to (name of the military hospital). Staff "E" stated she then went and notified the House Supervisor of the EMTALA violation, and explained the circumstances to her.

A telephone interview was conducted on 2/3/15 at approximately 8:00 p.m. with staff "F", who was in the ED during the incident on 1/3/15. She stated that the entire incident occurred over the time span of only a couple of minutes. She states that when EMS reported they were on the property, she went to the bay and looked outside and saw them approaching. She asked the charge nurse what to tell them, and she said to send them to the military hospital. She went outside and the ambulance rolled up. She spoke with the driver through the window and told them they want you to go to the military hospital. The driver made a comment about "breaking the law" and drove off. She states she was just trying to help speed up whatever was going to happen as they were very busy and all beds were full, and her only intent was to relay information and not to provide guidance or make any decisions.

The emergency department physician on duty at the time of the incident (staff "K") is unavailable for interview and currently out of the state.

Time line for ED census on 1/3/15 was provided by the Chief Executive Officer (CEO). The ED census prior to and at the time of the incident was as follows (the incident occurred between 10:47 pm and 11:39 pm on 1/3/15):
7:00pm-8:00pm: 15
8:00pm-9:00pm: 19
9:00pm-10:00pm: 17
10:00pm-11:00pm: 9
11:00pm-12:00am: 10

Twenty ED medical records were reviewed. All 20 medical records reviewed were found to appropriately reflect compliance with EMTALA requirements for a Medical Screening Exam, identification of an Emergency Medical Condition, stabilizing treatment, and appropriate transfer, when a transfer was determined to be necessary. There was no medical record for the patient who was transferred inappropriately (#21) because the patient was never brought into the ED at the hospital.

On 2/2/15 at approximately 12:10 p.m. a visit was made to the nursing home who sent the patient to the hospital ED. The nursing home Administrator provided a copy of the face sheet and nursing assessment notes leading up to the decision to send the patient out to the hospital. A review of the nursing notes revealed that the patient was transported to the hospital by EMS at around 11:20 p.m. on 1/3/15.

A review of the written statement provided by the EMS staff who was on the ambulance run has documentation only that the ambulance was dispatched on 1/3/15 at 10:47 p.m. to the nursing home, and arrived at 11:39, at the military hospital.
The hospital provided a copy of their policy entitled "EMATLA - Definitions and General Requirements", dated 3/2/2013, and approved by the Ethics and Compliance Policy Committee. The policy states, in part:

"A. General Requirements: Any hospital with an emergency department will provide to any individual who "comes to the emergency department" an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an EMC exists, regardless of the individual's ability to pay when a request is made by or on behalf of the individual for medical care, or a prudent layperson would observe that such care is needed, whether the individual is in the hospital's dedicated emergency department (DED) or elsewhere on the hospital's campus. EMTALA requires the hospital to do the following:
1. Provide an appropriate MSE to the individual within the capability of the hospital's emergency department to determine whether or not an EMC (emergency medical condition) exists."

The facility also provided a copy of their ED specific "EMTALA Florida Medical Screening Examination and Stabilizing Policy", dated last approved in 12/2014. The policy includes the following:
"An EMTALA obligation is triggered when an individual comes to a dedicated emergency department and: the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition, or a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition.

When an MSE is Required: A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists. An MSE shall be provided to determine whether or not the individual is experiencing an EMC or a pregnant woman is in labor. An MSE is required when: The individual comes to a dedicated emergency department of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition, including where:
i. The individual requests medication to resolve or provide stabilizing treatment for a medical
condition.
ii. The individual arrives as a transfer from another hospital or health care facility. Upon arrival of a transfer, a physician or qualified medical person ("QMP") must perform an appropriate MSE.
The Physician or QMP shall provide any additional screening and treatment required to stabilize the EMC. The MSE of the individual must be documented. This type of screening cannot be performed by the triage nurse. If an emergency medical condition is determined to exist and the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under EMTALA ceases.

Caution: If the ambulance staff disregards the hospital's instructions and brings the individual
on to hospital property, the individual has come to the emergency department and the hospital
must perform an appropriate MSE. Should a hospital which is not in official diversionary status
fail to accept a telephone or radio request for transfer or admission, the refusal could represent
a violation of other Federal or State regulations.

An interview was conducted with the hospital CEO (chief executive officer) on 2/3/15 at approximately 4:00 p.m. The CEO stated it was obvious that the charge nurse in the ED on 1/3/15, was responsible for EMS being turned away from the hospital and the hospital not providing the required MSE and stabilizing treatment. He stated that even though the ED was at capacity, and even though the hospital had no pulmonologist or neurosurgeon to treat the patient, they still had a responsibility to follow EMTALA requirements, and in this case that was not done. He stated that he views it as an isolated event. He reviewed the plan of correction and pointed out that the plan of correction has been fully implemented pending only the results of the Peer Review which will be completed when the ED physician on duty at the time of the event returns from vacation next week.

The survey was triggered based upon the hospital self-reporting the emergency access violation to the State of Florida Survey Agency. The self report included details of the event, and the hospital's plan of correction to ensure this type of incident will not occur in the future. The plan of correction includes the following:

1. The actions of the ED physician have been reported to the Peer Review Committee for review in accordance with the hospital Bylaws.
2. The CEO and ED Director will review and reevaluate the Hospital Diversion Policy, specifically the formula/process for determining criteria for over crowding.
3. Upon completion of the Diversion Policy review, education to the ED staff, ED Physicians and administrative supervisors on the appropriate procedures for implementing diversion status in the ED will be provided.
4. The Chief Nursing Officer (CNO) and ED Director completed an evaluation of the staffing patterns in the ED to ensure appropriate staffing during high volume time on 1/6/15.
5. The Respiratory Therapist who spoke with EMS was counseled regarding State Emergency Access laws and EMTALA Requirements.
6. ED, Respiratory Therapy, Security personnel, and all ED Physicians are currently receiving education regarding Florida's Emergency Access Laws and EMTALA requirements with all education to be completed no later than 1/31/15.

The review of the plan of correction revealed all corrective action has been completed as stated in the plan of correction with the exception of the verification of the completion of the PEER Review of the ED physician, at the time of the survey.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on review of written Emergency Medical Service (EMS) staff statement, Twin Cities Hospital written self-report of violation, review of Emergency Department policy and procedures and interviews with the hospital Chief Executive Officer (CEO), Quality/Risk Manager, Emergency Department (ED) Director, and other ED staff members, the hospital failed to provide Stabilizing Treatment for 1 of 21 patients in the sample (#21).

The findings are:

A written statement dated 1/3/15 was provided by the EMS (emergency medical services) paramedic who was in the ambulance with a patient being taken to the hospital ED. The statement is summarized as follows: On 1/3/15 at an undetermined time between 11:00 pm and 11:39 pm EMS contacted the hospital by radio to report they were bringing an unstable patient in respiratory distress, with brain cancer, and a valid Do Not Resuscitate Order (DNR) to the hospital. Before the EMS Paramedic "realized it", the ambulance was already on hospital property and pulling under the emergency room door's canopy. In the written statement provided by the Paramedic he states at that time a female instructed him over the radio that per the ED Physician, they were to divert to the areas military hospital. The Paramedic reports in his statement that he responded to the female that "we were on their property with an unstable patient. I asked if they still wanted EMS to divert. The response was "yes, take the patient to (name of military hospital)." The Paramedic reported in his statement that while the ambulance was stopped under the hospital ED canopy a nurse walked out to the ambulance and made contact with his partner who was in the driver seat. The Paramedic states he could not hear their conversation, but he stuck his head through the bulkhead and asked his partner to tell the nurse they were about to commit an EMTALA (Emergency Medical Treatment and Labor Act) violation. The Paramedic states he heard his partner tell the nurse this was against the law. He states they then diverted to the military hospital.

An interview was conducted on 2/2/15 at approximately 2:50 p.m. The Quality/ Risk manager (QRM) played 2 digital recordings from the EMS communication log. She stated these recordings were provided by the EMS dispatch, at the request of the hospital. The first recording was from the initial report given to the ED by EMS regarding the patient/ history and assessment. The charge nurse from the ED was speaking with the paramedic in the ambulance, on the radio. The paramedic reported the patient with oxygen saturation of 78%, history of terminal brain cancer, has a DNR (Do Not Resuscitate order), had vomited earlier in the evening, and was now with difficulty breathing. The paramedic did state that he was unsure if the patient had aspirated. He did state the lung sounds indicated congestion. The nurse informed him the patient needed to go to (name of a military hospital). The hospital account of the incident indicates the charge nurse had received a telephone report from a nurse at the sending nursing home facility regarding the patient. The nurse relayed the information from the nursing home report to the physician on duty in the ED. The physician then called the EMS dispatch to inform them that the ED was operating over capacity ("patients are stacked up like cord-wood"). This conversation was also recorded, and listened to. The physician stated that the hospital had no neurosurgery or pulmonologist capability and the ER was over capacity at that time. He informed EMS dispatch that the patient should go to local military hospital, as the family had requested that (per nursing report from the hospital), and he was currently receiving treatment from the military hospital for his brain cancer. By the time the conversation was over, EMS announced by radio that they were already on the hospital property. This communication was transmitted very soon after the initial EMS report was given via radio. The QRM was asked what times were recorded for both of these recorded communications, and she stated that the times were not provided by EMS dispatch.

A telephone interview was conducted on 2/3/15 at approximately 7:15 p.m. with ED staff nurse "E"., who was on shift in the ED on the night of 1/3/15: The nurse stated the nursing home had called and told them about a patient being transported by EMS to our ED because he was having breathing problems, and that he had brain cancer, and was a DNR, and the patient's family had wanted him to be taken to (name of military hospital) because that was where he was receiving the cancer treatment. EMS stated they were going to take the patient to the nearest hospital, which was our ED. It was a very busy shift, and all beds in the ED were full. She heard the ED physician say to get the EMS dispatch on the line because the patient should probably go to (name of military hospital) because the beds were full in the ED, and they have no on-call neurosurgeon or pulmonologist. At the time the physician was on the phone with EMS dispatch, the ambulance called on the radio to give report on the patient. The nurse could not hear all of the report because the nurse speaking on the radio kept keying the microphone while the paramedic was giving report, and that cut out his voice. She told the nurse taking report several times to stop keying the microphone because the paramedic couldn't hear her, and they couldn't hear report. The nurse taking report was trying to tell EMS to divert to the military hospital and EMS stated they were on hospital property. Just a moment later, they pulled up in the ambulance bay. A (respiratory therapist, staff "F") asked what she should tell them, and the nurse taking report told her to send them to the military hospital. Staff "E" claims to have stated "that is going to be an EMTALA violation". The ED Physician was still on the phone with EMS dispatch, and once he was informed the ambulance was on the property and in the bay, he terminated his call but the ambulance had already left the bay headed to (name of the military hospital). Staff "E" stated she then went and notified the House Supervisor of the EMTALA violation, and explained the circumstances to her.

A telephone interview was conducted on 2/3/15 at approximately 8:00 p.m. with staff "F", who was in the ED during the incident on 1/3/15. She stated that the entire incident occurred over the time span of only a couple of minutes. She states that when EMS reported they were on the property, she went to the bay and looked outside and saw them approaching. She asked the charge nurse what to tell them, and she said to send them to the military hospital. She went outside and the ambulance rolled up. She spoke with the driver through the window and told them they want you to go to the military hospital. The driver made a comment about "breaking the law" and drove off. She states she was just trying to help speed up whatever was going to happen as they were very busy and all beds were full, and her only intent was to relay information and not to provide guidance or make any decisions.

The emergency department physician on duty at the time of the incident (staff "K") is unavailable for interview and currently out of the state.

Time line for ED census on 1/3/15 was provided by the Chief Executive Officer (CEO). The ED census prior to and at the time of the incident was as follows (the incident occurred between 10:47 pm and 11:39 pm on 1/3/15):
7:00pm-8:00pm: 15
8:00pm-9:00pm: 19
9:00pm-10:00pm: 17
10:00pm-11:00pm: 9
11:00pm-12:00am: 10

Twenty ED medical records were reviewed. All 20 medical records reviewed were found to appropriately reflect compliance with EMTALA requirements for a Medical Screening Exam, identification of an Emergency Medical Condition, stabilizing treatment, and appropriate transfer, when a transfer was determined to be necessary. There was no medical record for the patient who was transferred inappropriately (#21) because the patient was never brought into the ED at the hospital.

On 2/2/15 at approximately 12:10 p.m. a visit was made to the nursing home who sent the patient to the hospital ED. The nursing home Administrator provided a copy of the face sheet and nursing assessment notes leading up to the decision to send the patient out to the hospital. A review of the nursing notes revealed that the patient was transported to the hospital by EMS at around 11:20 p.m. on 1/3/15.

A review of the written statement provided by the EMS staff who was on the ambulance run has documentation only that the ambulance was dispatched on 1/3/15 at 10:47 p.m. to the nursing home, and arrived at 11:39, at the military hospital.
An interview was conducted with the hospital CEO (chief executive officer) on 2/3/15 at approximately 4:00 p.m. The CEO stated it was obvious that the charge nurse in the ED on 1/3/15, was responsible for EMS being turned away from the hospital and the hospital not providing the required MSE and stabilizing treatment. He stated that even though the ED was at capacity, and even though the hospital had no pulmonologist or neurosurgeon to treat the patient, they still had a responsibility to follow EMTALA requirements, and in this case that was not done. He stated that he views it as an isolated event. He reviewed the plan of correction and pointed out that the plan of correction has been fully implemented pending only the results of the Peer Review which will be completed when the ED physician on duty at the time of the event returns from vacation next week.

The survey was triggered based upon the hospital self-reporting the emergency access violation to the State of Florida Survey Agency. The self report included details of the event, and the hospital's plan of correction to ensure this type of incident will not occur in the future. The plan of correction includes the following:
1. The actions of the ED physician have been reported to the Peer Review Committee for review in accordance with the hospital Bylaws.
2. The CEO and ED Director will review and reevaluate the Hospital Diversion Policy, specifically the formula/process for determining criteria for over crowding.
3. Upon completion of the Diversion Policy review, education to the ED staff, ED Physicians and administrative supervisors on the appropriate procedures for implementing diversion status in the ED will be provided.
4. The Chief Nursing Officer (CNO) and ED Director completed an evaluation of the staffing patterns in the ED to ensure appropriate staffing during high volume time on 1/6/15.
5. The Respiratory Therapist who spoke with EMS was counseled regarding State Emergency Access laws and EMTALA Requirements.
6. ED, Respiratory Therapy, Security personnel, and all ED Physicians are currently receiving education regarding Florida's Emergency Access Laws and EMTALA requirements with all education to be completed no later than 1/31/15.

The review of the plan of correction revealed all corrective action has been completed as stated in the plan of correction with the exception of the verification of the completion of the Peer Review of the ED physician, at the time of the survey.

The hospital provided a copy of their ED specific "EMTALA Florida Medical Screening Examination and Stabilizing Policy", dated last approved in 12/2014. The 14 page policy included the following:

An EMTALA obligation is triggered when an individual comes to a dedicated emergency department and: the individual or a representative acting on the individual's behalf requests an examination or treatment for a medical condition, or a prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition.

2. When an MSE is Required: A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the DED (dedicated emergency department), to determine whether or not an EMC exists. An MSE is required when: The individual comes to a dedicated emergency department of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition, including where:
i. The individual requests medication to resolve or provide stabilizing treatment for a medical
condition.
ii. The individual arrives as a transfer from another hospital or health care facility. Upon arrival of a transfer, a physician or qualified medical person ("QMP") must perform an appropriate MSE.
The Physician or QMP shall provide any additional screening and treatment required to stabilize
the EMC. The MSE of the individual must be documented. This type of screening cannot be
performed by the triage nurse.

8. Stabilizing Treatment within Hospital Capability; the determination of whether an individual is stable is not based on the clinical outcome of the individual ' s medical condition. An individual has been provided sufficient stabilizing treatment when, the physician treating the individual in the DED has determined within reasonable clinical confidence no material deterioration of the condition is likely, within reasonable medical probability, to result from, or occur during , the transfer of the individual from a facility ... b. Stabilizing Treatment Within Hospital Capability and Transfer. Once the hospital has provided an appropriate MSE and stabilizing treatment within its capability, an appropriate transfer may be effected ... Refer to the hospital ' s Transfer Policy for additional directions regarding transfers of those individuals who are not medically stable if a hospital has exhausted all its capabilities and is unable to stabilize an individual, an appropriate transfer should be implemented by the transferring physician.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on review of written Emergency Medical Service (EMS) staff statements, Twin Cities Hospital written self-report of violation, review of Emergency Department policy and procedures, and interviews with the hospital Chief Executive Officer (CEO), Quality/Risk Manager, Emergency Department (ED) Director, and other ED staff members, the hospital failed to provide an Appropriate Transfer of a patient with a reported unstable emergency medical condition for 1 of 21 patients in the sample (#21).

The findings are:

A written statement dated 1/3/15 was provided by the EMS (emergency medical services) paramedic who was in the ambulance with a patient being taken to the hospital ED. The statement is summarized as follows: On 1/3/15 at an undetermined time between 11:00 pm and 11:39 pm EMS contacted the hospital by radio to report they were bringing an unstable patient in respiratory distress, with brain cancer, and a valid Do Not Resuscitate Order (DNR) to the hospital. Before the EMS Paramedic "realized it", the ambulance was already on hospital property and pulling under the emergency room door's canopy. In the written statement provided by the Paramedic he states at that time a female instructed him over the radio that per the ED Physician, they were to divert to the areas military hospital. The Paramedic reports in his statement that he responded to the female that "we were on their property with an unstable patient. I asked if they still wanted EMS to divert. The response was "yes, take the patient to (name of military hospital)." The Paramedic reported in his statement that while the ambulance was stopped under the hospital ED canopy a nurse walked out to the ambulance and made contact with his partner who was in the driver seat. The Paramedic states he could not hear their conversation, but he stuck his head through the bulkhead and asked his partner to tell the nurse they were about to commit an EMTALA (Emergency Medical Treatment and Labor Act) violation. The Paramedic states he heard his partner tell the nurse this was against the law. He states they then diverted to the military hospital.

An interview was conducted on 2/2/15 at approximately 2:50 p.m. The Quality/ Risk manager (QRM) played 2 digital recordings from the EMS communication log. She stated these recordings were provided by the EMS dispatch, at the request of the hospital. The first recording was from the initial report given to the ED by EMS regarding the patient/ history and assessment. The charge nurse from the ED was speaking with the paramedic in the ambulance, on the radio. The paramedic reported the patient with oxygen saturation of 78%, history of terminal brain cancer, has a DNR (Do Not Resuscitate order), had vomited earlier in the evening, and was now with difficulty breathing. The paramedic did state that he was unsure if the patient had aspirated. He did state the lung sounds indicated congestion. The nurse informed him the patient needed to go to (name of a military hospital). The hospital account of the incident indicates the charge nurse had received a telephone report from a nurse at the sending nursing home facility regarding the patient. The nurse relayed the information from the nursing home report to the physician on duty in the ED. The physician then called the EMS dispatch to inform them that the ED was operating over capacity ("patients are stacked up like cord-wood"). This conversation was also recorded, and listened to. The physician stated that the hospital had no neurosurgery or pulmonologist capability and the ER was over capacity at that time. He informed EMS dispatch that the patient should go to local military hospital, as the family had requested that (per nursing report from the hospital), and he was currently receiving treatment from the military hospital for his brain cancer. By the time the conversation was over, EMS announced by radio that they were already on the hospital property. This communication was transmitted very soon after the initial EMS report was given via radio. The QRM was asked what times were recorded for both of these recorded communications, and she stated that the times were not provided by EMS dispatch.

A telephone interview was conducted on 2/3/15 at approximately 7:15 p.m. with ED staff nurse "E"., who was on shift in the ED on the night of 1/3/15: The nurse stated the nursing home had called and told them about a patient being transported by EMS to our ED because he was having breathing problems, and that he had brain cancer, and was a DNR, and the patient's family had wanted him to be taken to (name of military hospital) because that was where he was receiving the cancer treatment. EMS stated they were going to take the patient to the nearest hospital, which was our ED. It was a very busy shift, and all beds in the ED were full. She heard the ED physician say to get the EMS dispatch on the line because the patient should probably go to (name of military hospital) because the beds were full in the ED, and they have no on-call neurosurgeon or pulmonologist. At the time the physician was on the phone with EMS dispatch, the ambulance called on the radio to give report on the patient. The nurse could not hear all of the report because the nurse speaking on the radio kept keying the microphone while the paramedic was giving report, and that cut out his voice. She told the nurse taking report several times to stop keying the microphone because the paramedic couldn't hear her, and they couldn't hear report. The nurse taking report was trying to tell EMS to divert to the military hospital and EMS stated they were on hospital property. Just a moment later, they pulled up in the ambulance bay. A (respiratory therapist, staff "F") asked what she should tell them, and the nurse taking report told her to send them to the military hospital. Staff "E" claims to have stated "that is going to be an EMTALA violation". The ED Physician was still on the phone with EMS dispatch, and once he was informed the ambulance was on the property and in the bay, he terminated his call but the ambulance had already left the bay headed to (name of the military hospital). Staff "E" stated she then went and notified the House Supervisor of the EMTALA violation, and explained the circumstances to her.

A telephone interview was conducted on 2/3/15 at approximately 8:00 p.m. with staff "F", who was in the ED during the incident on 1/3/15. She stated that the entire incident occurred over the time span of only a couple of minutes. She states that when EMS reported they were on the property, she went to the bay and looked outside and saw them approaching. She asked the charge nurse what to tell them, and she said to send them to the military hospital. She went outside and the ambulance rolled up. She spoke with the driver through the window and told them they want you to go to the military hospital. The driver made a comment about "breaking the law" and drove off. She states she was just trying to help speed up whatever was going to happen as they were very busy and all beds were full, and her only intent was to relay information and not to provide guidance or make any decisions.

The emergency department physician on duty at the time of the incident (staff "K") is unavailable for interview and currently out of the state.

Time line for ED census on 1/3/15 was provided by the Chief Executive Officer (CEO). The ED census prior to and at the time of the incident was as follows (the incident occurred between 10:47 pm and 11:39 pm on 1/3/15):
7:00pm-8:00pm: 15
8:00pm-9:00pm: 19
9:00pm-10:00pm: 17
10:00pm-11:00pm: 9
11:00pm-12:00am: 10

Twenty ED medical records were reviewed. All 20 medical records reviewed were found to appropriately reflect compliance with EMTALA requirements for a Medical Screening Exam, identification of an Emergency Medical Condition, stabilizing treatment, and appropriate transfer, when a transfer was determined to be necessary. There was no medical record for the patient who was transferred inappropriately (#21) because the patient was never brought into the ED at the hospital.

On 2/2/15 at approximately 12:10 p.m. a visit was made to the nursing home who sent the patient to the hospital ED. The nursing home Administrator provided a copy of the face sheet and nursing assessment notes leading up to the decision to send the patient out to the hospital. A review of the nursing notes revealed that the patient was transported to the hospital by EMS at around 11:20 p.m. on 1/3/15.

A review of the written statement provided by the EMS staff who was on the ambulance run has documentation only that the ambulance was dispatched on 1/3/15 at 10:47 p.m. to the nursing home, and arrived at 11:39, at the military hospital.

An interview was conducted with the hospital CEO (chief executive officer) on 2/3/15 at approximately 4:00 p.m. The CEO stated it was obvious that the charge nurse in the ED on 1/3/15, was responsible for EMS being turned away from the hospital and the hospital not providing the required MSE and stabilizing treatment. He stated that even though the ED was at capacity, and even though the hospital had no pulmonologist or neurosurgeon to treat the patient, they still had a responsibility to follow EMTALA requirements, and in this case that was not done. He stated that he views it as an isolated event. He reviewed the plan of correction and pointed out that the plan of correction has been fully implemented pending only the results of the Peer Review which will be completed when the ED physician on duty at the time of the event returns from vacation next week.

The survey was triggered based upon the hospital self-reporting the emergency access violation to the State of Florida Survey Agency. The self report included details of the event, and the hospital's plan of correction to ensure this type of incident will not occur in the future. The plan of correction includes the following:

1. The actions of the ED physician have been reported to the Peer Review Committee for review in accordance with the hospital Bylaws.
2. The CEO and ED Director will review and reevaluate the Hospital Diversion Policy, specifically the formula/process for determining criteria for over crowding.
3. Upon completion of the Diversion Policy review, education to the ED staff, ED Physicians and administrative supervisors on the appropriate procedures for implementing diversion status in the ED will be provided.
4. The Chief Nursing Officer (CNO) and ED Director completed an evaluation of the staffing patterns in the ED to ensure appropriate staffing during high volume time on 1/6/15.
5. The Respiratory Therapist who spoke with EMS was counseled regarding State Emergency Access laws and EMTALA Requirements.
6. ED, Respiratory Therapy, Security personnel, and all ED Physicians are currently receiving education regarding Florida's Emergency Access Laws and EMTALA requirements with all education to be completed no later than 1/31/15.

The review of the plan of correction revealed all corrective action has been completed as stated in the plan of correction with the exception of the verification of the completion of the Peer Review of the ED physician, at the time of the survey.

The hospital provided a copy of their ED specific "EMTALA Florida Medical Screening Examination and Stabilizing Policy", dated last approved in 12/2014. The 14 page policy included the following:

8. Stabilizing Treatment within Hospital Capability; the determination of whether an individual is stable is not based on the clinical outcome of the individual's medical condition. An individual has been provided sufficient stabilizing treatment when, the physician treating the individual in the DED has determined within reasonable clinical confidence no material deterioration of the condition is likely, within reasonable medical probability, to result from, or occur during , the transfer of the individual from a facility ... b. Stabilizing Treatment Within Hospital Capability and Transfer. Once the hospital has provided an appropriate MSE and stabilizing treatment within its capability, an appropriate transfer may be effected ... Refer to the hospital's Transfer Policy for additional directions regarding transfers of those individuals who are not medically stable if a hospital has exhausted all its capabilities and is unable to stabilize an individual, an appropriate transfer should be implemented by the transferring physician.

The hospital also provided a copy of their "EMTALA Transfer Policy", dated last approved 12/2014. The 13 page policy included the following:

Procedures: 1. Transfers of Individuals Who Are Not Medically Stable. Requirements Prior to Transfer: After the hospital has provided medical treatment within its capability to minimize the risks to the health of an individual with an EMC who is not medically stable, the hospital may arrange an appropriate transfer for the individual to another more appropriate or specialized facility. Evaluation and treatment shall be performed and transfer shall be carried out as quickly as possible for an individual with an emergency medical condition which has not been stabilized or when stabilization of the individual ' s vital signs is not possible because the hospital does not have the appropriate equipment or personnel to correct the underlying process.