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.

LAWNWOOD REGIONAL MEDICAL CENTER & HEART INSTITUTE 1700 S 23RD ST FORT PIERCE, FL 34950 Sept. 4, 2015
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on documentation review, staff interview and policy review, Lawnwood Regional Medical Center & Heart Institute failed to comply with the Requirements at 42 CFR 489.24. The hospital emergency service personnel failed to accept a patient on whose behalf a request was made to transfer the patient in to their facility, from another local hospital, for a higher level of care / service within the facility's capabilities and capacity. The failure affected 1 of 20 sampled patients, Patient #1. See findings at A2411.
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
Based on documentation review and staff interviews, the facility failed to ensure the provision of services within the specialized capabilities and capacity of the hospital. This affected one (1) of 20 Emergency Department (ED) sampled patients whose medical records were reviewed, Patient #1, who was not accepted when on behlf of the patient a transfer request for emergency care and services was made. The services request was available at the time at Lawnwood Regional Medical Center.

The findings include:

Review of the facility license revealed the facility offers itself to the general public as providing services which includes Vascular as well as it is a Level 2 Trauma Center.

Review of the facility policy titled "Florida EMTALA Transfer Policy", policy number EMT001.002 revealed: 'to establish guidelines for either accepting an appropriate transfer from another or providing appropriate transfer to another facility of an individual with an emergency medical condition (EMC) who requests or requires a transfer for further medical care and follow-up to a receiving facility ... ' . The policy included: 'A hospital with specialized capabilities or facilities shall accept from a transferring hospital an appropriate transfer of an individual with an EMC who requires specialized capabilities if the receiving hospital has the capacity to treat the individual'; Under 1c. Higher Level Of Care: 'A higher level of care should be the more likely reason to transfer an individual with and EMC that has not been stabilized. The following are examples of higher level of care: i. A receiving hospital with specialized capabilities or facilities that are available at the transferring hospital ...must accept an appropriate transfer of an individual with an EMC who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual'.
Further review of this policy under 3. Authority to Accept a Transfer revealed: 'The Emergency Physician and the Hospital CEO or designee, such as the administrator on call or the house supervisor are the ONLY individuals authorized to accept or refuse the transfer of an individual from another facility on behalf of the receiving hospital.' Under 5 - 3. 'The on-call physician does not have the authority to refuse an appropriate transfer on behalf of the facility'.

Patient #1 did not physically present to Lawnwood Regional Medical Center (Hospital B) the ED (Emergency Department) on 7/29/15. Review of the documentation provided by Hospital B revealed Hospital A (transferring hospital) called Hospital B on 07/29/2015 at 00:23 AM related to a patient (#1) who had sustained an Arterial Bleed to the left forearm. The documented preliminary diagnosis Brachial Artery Laceration x 2 with Arterial Bleed to lower muscle. The form also document additional Information of: left arm and bilateral feet second degree burns, abdomen burns, No radial pulse to left. The Trauma doctor was contacted (consulted) at 0029 AM. Documented under the section on the Form for accept or decline is the patient was declined for transfer. The nurse documented on this Form: '2 units O-negative blood; Diaphoretic. At 00:34 AM; a call was made to ED director related to transfer being declined ...awaiting further details". Review of the Detailed Report for Declining Transfers revealed: The services being requested is Trauma. Under detailed reason transfer was declined is: 'Trauma MD (physician) states patient needs burn center ...MD declined ...Call to ED Director ...he called the medical trauma director ...the medical trauma director called ED director back stating to allow patient to go to Hospital D (which is in another county). There is no evidence Patient #1 was accepted by a physician at Hospital B for emergency services/further treatment and stabilization. Review of the license for Hospital A disclose it does not have Vascular nor Burn services on its Invertory of Services provided.

Interview with the Director of Ethics and Compliance on 9/1/15 at approximately 9:18 AM revealed: Hospital B's (Lawnwood Regional Medical Center) trauma surgeon told Hospital A he could treat the laceration and didn't have the capability to treat burns.

Interview with the Director of Nursing Administration on 9/01/15 at approximately 9:20 AM revealed Lawnwood Regional Medical Center can treat burns that are not extensive, but typically if extensive, would transfer such patients out to a Burn Center. She doesn't know if Patient #1 had extensive burns or not. Sample selection review substantiates the administrator's statement regarding the capability and capacity to render care for non-extensive burns. The Director of Ethnics and Compliance said this trauma Surgeon is no longer on medical staff anymore but has moved up North. The surgeon's last day working at Hospital B was 7/29/15 as per the Chief of Nursing Officer.

Interview with the ED Director on 9/01/15 at approximately 9:38 AM revealed patients being transferred in go through the facility's ransfer Center, which would call the ED charge nurse; the ED physicians would speak to the transferring physician and they usually accept the patient. If there is an issue with accepting a transfer-in, the staff would notify the CNO (Chief nursing officer) or designee / AOC =administrator on call; If the patient was a trauma patient, they would consult with the surgeon on the phone. The ED Director said for Patient
#1, both Hospital A and Hospital B surgeons spoke together and agreed Patient #1 would be better served at a Burn Center. The ED Director said they spoke of sending the patient to Hospital D (in another county) but the patient actually went to Hospital C (another local hospital). The ED Director said the administrator on call was called but did not answer the phone at the time the Transfer Center called.

Interview with the ED Medical Director on 9/1/15 at approximately 10:05 AM revealed Patient #1 should have been accepted as we had the capability and capacity at the time. He said Lawnwood Regional Medical Center could assess the Patient, treat and transfer out if necessary for the burns.
Review of Hospital B's ED clinical file, dated 7/29/15 at 01:00 AM, revealed Patient #1 presented to their ED with chief complaint of Wound Evaluation. The patient is triaged as Emergent / level 2 according to the triage notes. The nurse documented left brachial two open lacerations, abdominal burn redness noted, left arterial bleed. The nurse documented the wound as: laceration; minor burn. The nurse documented the patient was given 2 units of blood. The physician assessed the patient and documented a Primary Impression of Vascular Injury left Upper extremity and condition Critical. The patient was air-lifted to Hospital C, after being declined transfer to Hospital B.

Review of Hospital C's ED record for Patient #1 revealed: according to the triage nurse documentation, Patient #1 arrived on 7/29/15 at 01:56 AM via helicopter for Brachial Arm Laceration; superficial burns to abdomen. The ED physician documented chief complaint as: chemical burn and laceration to arm; burn type & severity of 1st degree; laceration related to explosion. Hospital C's Trauma Surgeon documented: seen with 2nd degree burn which are scattered to left arm and abdomen and also a deep laceration to left forearm which is actually bleeding. The skin examination includes: scattered 2nd degree burn left forearm and few to abdomen. The physician documented, the patient was taken to the Operating room immediately for left arm laceration repair (02:10 AM). Review of the Discharge summary revealed on 7/30/15, the patient was discharged with wound healing well, with good arm pulse and a blister to the abdomen.

Review of audio-tape provided of the 7/29/15 transfer call revealed Hospital a, via the Transfer Center, called Hospital B to request a transfer of patient #1 to Hospital B. The physician conversation includes: Hospital A - 'left arm with vascular bleeding, no pulse arm, can't see where the vessel is lacerated, Scattered second degree burns belly, not much, both feet with 2nd degree burns on tops noncircular down to toes; Needs burn care but needs laceration care first'. Hospital B's trauma surgeon replied: recommend sending to a Trauma and Burn Center. The Trauma Surgeon at Hospital A declined the transfer of Patient #1 saying the patient needs a Burn Center otherwise I'd have to address this and kick him out. The Transfer Center then intercepted and said 'will call Hospital D as recommended by trauma surgeon, as critical'. The Transfer Center said to Hospital b's ED nurse: you are declining the patient? The nurse asked the trauma surgeon if the patient was declined and the trauma surgeon agreed and the nurse answered the patient is being declined transfer to Hospital b.

Further interview with the Chief Nursing Officer, the Director of Patient Safety / Risk Manager, and the ED Nurse Director revealed they concurred, Patient #1 should have been accepted by the facility based on service capability and capacity.