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 Sept. 26, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on video surveillance review, clinical record review, policy review and staff interviews the facility failed to adopt and enforce policies and procedures to ensure compliance with the EMTALA requirements at 42 CFR 489.24 This failure affected 1 of 21 sampled patients (Patient #21)

The findings included:


1. Based on review of medical records, video surveillance review, Medical Staff Rules and Regulations review, policy and procedure review, and staff interviews, it was determined, the facility failed to ensure that an appropriate medical screening examination was provided as required, that was within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed after a request was made on an individual's behalf for an examination and treatment for 1 of 21 sampled patients (Patient #21). Please refer to findings in Citation A- 2406.


2. Based on review of medical records, video surveillance review, policy and procedure review, and staff interviews, it was determined, the facility failed to substantiate the provision of emergency services for 1 of 21 sampled patients (Patient #21) as evidenced by lack of a medical screening exam within their capabilities and failure to provide care and treatment to stabilize the medical condition. Please refer to findings in Citation A- 2407.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on surveillance video, medical record review, Emergency Department Central Log review, policy review and interview, it was determined, the facility failed to ensure the central log included all individuals who presented to the Emergency Department (ED) seeking treatment. This failure affected 1 of 21 sample patients (Patient #21).

The findings included:


Review of the facility video surveillance conducted on 09/25/19 while accompanied by The Risk Manager revealed on 09/06/19 at 8:31 PM a vehicle arriving to the ED parking lot. The video shows a male getting out of the vehicle and going inside the Emergency Department (ED) to get a wheelchair. The male returned to the vehicle with the wheelchair. A few minutes later, a female (later identified as the mother) went inside the ED lobby multiple times. At 8:50 PM, a young male, identified as Patient #21, the male and the mother walked towards the ED entrance. They stopped by the handicap parking space, next to a parked vehicle similar, to the one they arrived in. Patient #21 is seen pacing back and forth and grabbing his head on and off. At 8:53 PM a security staff arrives to the scene. The mother is seen going in and out of the ED multiple times. Another female is seen accompanying the mother from the ED to the area where they were standing (the hospital staff could not identify the female, most likely a visitor). At 8:54 PM another security staff approaches the area; at 8:58 PM a staff member identified as the patient care technician is seen leaving the ED and approaching the area with another wheelchair. The mother and the male are seeing talking to the security guard. At 9:02 PM the charge nurse and a security guard are seen approaching the area and talking to the mother. Patient #21 remained pacing back and forth and holding his head on and off. At 9:09 PM the charge nurse returned back to the ED and Patient #21, the mother and the male walked back to their car and left the parking lot at 9:13 PM.


Review of the facility central logs conducted on 09/25/19 failed to provide evidence that Patient #21 (MDS) dated [DATE] seeking care.

Interview with Staff F, The Charge Nurse on duty on 09/06/19, was conducted on 09/25/19 at 1:12 PM. Staff F explained his recollection of the events by saying the patient's mother first came into the ED asking for assistance to get the patient out of the car, then came back in, insisting the patient be restrained to get him into the ED. Staff F explained to the mother they would not do so; the patient was not violent and that he needed to come inside for registration. The patient was awake, seem to be in no distress and did not speak. Staff F was asked if the patient seem able to consent to treatment, and he replied the patient seem autistic and the mother was doing all the talking. Staff F was asked what reason the mother gave for coming to the ED and replied she stated she could not handle him anymore. Staff F was asked if he asked for the patient's name and replied he asked multiple times and the mother refused to give a name unless the patient was restrained and brought inside. Staff F stated the patients have to be registered first in order to be seen by the providers. Then the mother decided to leave, got in their car and left the area. Staff F confirmed Patient #21 was not logged into the central log.


Phone interview with The Medical Director conducted on 09/26/19 at 9:20 AM revealed he just learned about the incident today. The Medical Director clarified providers will see patients before they get logged in or registered in the system, they will go outside and address any issues. All providers received EMTALA education and they understand the 250 - Yard rule.


Phone interview with Staff G, a Security Officer, conducted on 09/25/19 at 5:24 PM revealed the patient and family members were in the parking lot, the patient seemed mentally disabled, he was walking around, he overheard that he was aggressive, so he did not get too close to the patient. The mother was saying he needed some type of medication or IV (intravenous). The security guard called to get the charge nurse and soon after the charge nurse and a patient care technician came out to talk to the mother. Staff G does not recall anyone trying to get the patient's name, he could hear the conversation between the mother and the charge nurse and the mother was requesting the patient be restrained and the nurse explained he could not do that. Then the mother and patient walked back to their car and drove off.


Phone interview with Staff H, a Security Officer, conducted on 09/25/19 at 5:42 PM revealed when he arrived to the scene, the mother, the patient and another person were outside in the parking lot. He recalls the mother was asking for a Benadryl shot or something like that. The patient did not want to get in the wheelchair and come inside the ED. He was not combative, he was hugging the mom and walking back and forth. The patient seemed like he had dow[DIAGNOSES REDACTED] and was agitated. He recalls the mother called the patient ( by "Nickname"). Soon after, the charge nurse came out to address the situation and he (staff H) stepped back.


Phone interview with Staff K, a Paramedic conducted on 09/26/19 at 11:44 AM revealed she was working on the triage area the evening of September 6th, it was a busy night and something was going on outside with security and the patient care technician. Staff K went outside to assist with the situation and recalls how much the patient's mother wanted the son to be checked out and the charge nurse told him, they couldn't treat him unless he comes inside. The mother asked for the patient to be restrained and the nurse explained we could not do so. Then, Staff K asked the charge nurse if he needed further assistance from her, he nodded no and she return to the ED.

The facility's policy titled "Medical Emergency Response" last revised 11/17 was reviewed. The policy revealed that any patient presenting to the Emergency Department will be listed in the facility's emergency department log.

Facility policy titled EMTALA Patient Presentation within 250 yards of Main Building or Directly to Emergency Department, effective 08/05/19 documents revealed in part, "Whenever a patient presents to the hospital campus, whether walking, by EMS, or a private vehicle, several actions must be implemented.
The patient arrival must be logged into EPIC ( Electronic medical record system) and a medical record must be created." The facility failed to ensure that their policy and procedure was followed as evidenced by failing to ensure that on 9/6/2019 Patient #21 was logged into the facility's EPIC computerized system.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, video surveillance review, Medical Staff Rules and Regulations review, policy and procedure review, and staff interviews, it was determined, the facility failed to ensure that an appropriate medical screening examination was provided as required, that was within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed after a request was made on an individual's behalf for an examination and treatment for 1 of 21 sampled patients (Patient #21).


The findings included:


Review of the facility video surveillance conducted on 09/25/19 while accompanied by The Risk Manager revealed on 09/06/19 at 8:31 PM a vehicle arriving to the ED parking lot. The video shows a male getting out of the vehicle and going inside the Emergency Department (ED) to get a wheelchair. The male returned to the vehicle with the wheelchair. A few minutes later, a female (later identified as the mother) went inside the ED lobby multiple times. At 8:50 PM, a young male, identified as Patient #21, the male and the mother walked towards the ED entrance. They stopped by the handicap parking space, next to a parked vehicle similar, to the one they arrived in. Patient #21 is seen pacing back and forth and grabbing his head on and off. At 8:53 PM a security staff arrives to the scene. The mother is seen going in and out of the ED multiple times. Another female is seen accompanying the mother from the ED to the area where they were standing (the hospital staff could not identify the female, most likely a visitor). At 8:54 PM another security staff approaches the area; at 8:58 PM a staff member identified as the patient care technician is seen leaving the ED and approaching the area with another wheelchair. The mother and the male are seen talking to the security guard. At 9:02 PM the charge nurse and a security guard are seen approaching the area and talking to the mother. Patient #21 remained pacing back and forth and holding his head on and off. At 9:09 PM the charge nurse returned to the ED and Patient #21, the mother and the male walked back to their car and left the parking lot at 9:13 PM.


Review of the clinical records from Facility B revealed Patient #21 presented to their emergency department on 09/06/19 at 10:04 PM for possible reaction to medication. The same complaints reported at Facility A. The medical screening exam dated 09/06/19 documents the patient has history of dow[DIAGNOSES REDACTED], psychiatric issues, [DIAGNOSES REDACTED], autism and acute agitation and now concerns for tardive dyskinesia. The history was obtained from the mother who is the primary care taker. The patient was recently started on a new medication, Cogentin, and since then has exhibited abnormal movements, change on level of consciousness, agitation and gagging. The patient was just outside the vehicle in ambulance bay refusing to enter the hospital and becoming physically aggressive with mother and staff, swinging arms and grabbing clothes. The patient required physical restraints and was given ketamine, which minimally improved his agitation. The patient was intubated and subsequently admitted to the facility.
History and Physical dated 09/07/19 documents the patient was admitted with Septic Shock (a condition sometimes occurring in severe sepsis, in which the blood pressure fails and the organs of the body fail to receive sufficient oxygen), Tardive Dyskinesia (a neurological disorder characterized by involuntary movements of the face and jaw, commonly caused by long term use of antipsychotic medications) and Disruptive Behavior.
Progress Notes dated 09/07/19 documents the patient is febrile with elevated lactic acid. The results of a pulmonary angiogram showed bibasilar atelectasis, cardiomegaly and central vascular congestion.
Progress Notes dated 09/14/19 documents the patient has acute respiratory failure with extensive pulmonary infiltrates in pulmonary edema pattern and remained in intensive care. Patient #21 was transferred to "Hospice House" on 9/26/2019 in serious condition and expired on [DATE].



Interview with Staff F, The Charge Nurse on duty on 09/06/19, was conducted on 09/25/19 at 1:12 PM. Staff F explained his recollection of the events by saying the patient's mother first came into the ED asking for assistance to get the patient out of the car, then came back in insisting the patient be restrained to get him into the ED. Staff F explained to the mother they would not do so; the patient was not violent and that he needed to come inside for registration. The patient was awake, seem to be in no distress and did not speak. Staff F was asked if the patient seem able to consent to treatment, and he replied the patient seem autistic and the mother was doing all the talking. Staff F was asked what reason the mother gave for coming to the ED and replied she stated she could not handle him anymore. Staff F was asked if he asked for the patient's name and replied he asked multiple times and the mother refused to give a name unless the patient was restrained and brought inside. Staff F confirmed he did not advise any of the providers on duty of the situation to facilitate a medical screening exam, it was a busy night, the ED was overwhelmed with patients. The facility failed to ensure that their policy and procedure titled "Medical Emergency Response" was followed as evidenced by failing to ensure that on 9/6/2019 Patient #21, who was seen on video surveillance as agitated and pacing back and forth in the facility's ED parking lot; and required a medical assistance/medical screening examination by an Emergency Physician and or other Qualified Medical Personal to determine whether or not an emergency medical condition existed.


Phone interview with The Medical Director conducted on 09/26/19 at 9:20 AM revealed he just learned about the incident today. The medical staff takes EMTALA guidelines very seriously and understand the obligation to see any patient with a perception of an emergent complaint.

Phone interview with Staff J, a physician, conducted on 09/26/19 at 9:56 AM revealed she was on duty the evening of September 6th and was not aware of the incident until ten minutes ago, when the medical director informed her of the situation.

Phone interview Staff M, a Physician Assistant on duty the evening of September 6th, conducted on 09/26/19 at 12:30 PM revealed he had no knowledge of the incident then or now.

Phone interview with Staff K, a Paramedic conducted on 09/26/19 at 11:44 AM revealed she was working on the triage area the evening of September 6th, it was busy night and something was going on outside with security and the patient care technician. Staff K went outside to assist with the situation and recalls how much the patient's mother wanted the son to be checked out and the charge nurse told him, they couldn't treat him unless he comes inside. The mother asked for the patient to be restrained and the nurse explained we could not do so. Then, she asked the charge nurse if he needed further assistance from her, he nodded no, and she return to the ED.


Phone interview with Staff N, a Patient Care Technician, conducted on 09/26/19 at 12:37 PM revealed she arrived at the incident right after the charge nurse and only recalls the patient's mother saying we are leaving, she said if you can't treat him, I will take him to L .... hospital.


Review of the electronic clinical records conducted on 09/25/19 provides no documented evidence of the provision of a medical screening examination on 09/06/19 for patient #1.

The facility's Policy titled "Medical Emergency Response", last revised 11/17, was reviewed. The policy revealed in part,"Once a person is requires medical assistance on the hospital campus, the determination of whether an emergency medical condition exists will be made by the examining physician(s) or other qualified medical personnel."

Facility policy titled EMTALA Patient Presentation within 250 yards of Main Building or Directly to Emergency Department, effective 08/05/19 documents "To ensure that any patient on the hospital campus as defined in Administrative policy 01.23-2. Emergency Medical Services 250-yard rule and requests emergency services or who would appear to a reasonable prudent person to need medical attention must be provided with an appropriate medical screening examination to determine if he is suffering from an emergency medical condition. . . The medical screening examination must be documented in the medical record."


Facility policy Emergency Medical Services 250 Yard Rule, last revised 07/17 documents the hospital campus is defined as the physical area immediately adjacent to or in main buildings, and other structures owned by the hospital that are not contiguous to the main buildings but are located within 250 yards of the main buildings. . . Emergency Medical Services: It is the policy of Martin Health Systems that any person who comes to the emergency department, on hospital property, or on the hospital campus, (as defined above) and requests examination for, or in the absence of a request any prudent layperson observer would conclude from the persons appearance or behavior a need for examination or treatment of an emergency medical condition, will assist in obtaining appropriate assistance for such person.
Response to Medical Emergencies on hospital Property: To the extent Martin Health System Associates are aware of an individual on hospital property or a hospital campus (as defined above) who may be perceived as requiring emergency medical treatment, they shall follow the process standard on responses to medical emergencies.

Medical Staff Rules and Regulations, Board Policies, documents It is the policy of The Board of Directors of Martin Memorial Medical Center, Inc, which includes Tradition Medical Center, the following persons are authorized to conduct medical screening examinations: A physician which include a doctor of medicine or osteopathy, a doctor of dental surgery and a doctor of podiatry medicine if credentialed to do so. An Advance Registered Nurse Practitioner, . . . a Physician Assistant if privileged to do so . . ."


The facility also failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that on 9/6/2019 patient #1 who was agitated, pacing in the parking area, and came to the facility's emergency department parking lot; and a prudent layperson (patient #1's mother) requested the need for medical attention. The facility failed to ensure that an appropriate medical screening examination was provided to determine if Patient #21 was suffering from an emergency medical condition on 9/6/2019.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on review of medical records, video surveillance review, policy and procedure review, and staff interviews, it was determined, the facility failed to ensure the provision of emergency services within the capabilities of the hospital and failure to provide care and treatment to stabilize the medical condition for 1 of 21 sampled patients (Patient #21).

The findings included:

Review of the facility video surveillance conducted on 09/25/19 while accompanied by The Risk Manager revealed on 09/06/19 at 8:31 PM a vehicle arriving to the ED parking lot. The video shows a male getting out of the vehicle and going inside the Emergency Department (ED) to get a wheelchair. The male returned to the vehicle with the wheelchair. A few minutes later, a female (later identified as the mother) went inside the ED lobby multiple times. At 8:50 PM, a young male, identified as Patient #21, the male and the mother walked towards the ED entrance. They stopped by the handicap parking space, next to a parked vehicle similar, to the one they arrived in. Patient #21 is seen pacing back and forth and grabbing his head on and off. At 8:53 PM a security staff arrives to the scene. The mother is seen going in and out of the ED multiple times. Another female is seen accompanying the mother from the ED to the area where they were standing (the hospital staff could not identify the female, most likely a visitor). At 8:54 PM another security staff approaches the area; at 8:58 PM a staff member identified as the patient care technician is seen leaving the ED and approaching the area with another wheelchair. The mother and the male are seen talking to the security guard. At 9:02 PM the charge nurse and a security guard are seen approaching the area and talking to the mother. Patient #21 remained pacing back and forth and holding his head on and off. At 9:09 PM the charge nurse returned to the ED and Patient #21, the mother and the male walked back to their car and left the parking lot at 9:13 PM.


Interview with Staff F, The Charge Nurse on duty on 09/06/19, was conducted on 09/25/19 at 1:12 PM. Staff F explained his recollection of the events by saying the patient's mother first came into the ED asking for assistance to get the patient out of the car, then came back in insisting the patient be restrained to get him into the ED. Staff F explained to the mother they would not do so; the patient was not violent and that he needed to come inside for registration. The patient was awake, seem to be in no distress and did not speak. Staff F was asked if the patient seemed able to consent to treatment, and he replied the patient seem autistic and the mother was doing all the talking. Staff F was asked what reason the mother gave for coming to the ED and replied she stated she could not handle him anymore. Staff F was asked if he asked for the patient's name and replied he asked multiple times and the mother refused to give a name unless the patient was restrained and brought inside. Staff F confirmed he did not advise any of the providers on duty of the situation to facilitate a medical screening exam, it was a busy night.


Phone interview with The Medical Director conducted on 09/26/19 at 9:20 AM revealed he just learned about the incident today. The medical staff takes EMTALA guidelines very seriously and understand the obligation to see any patient with a perception of emergent complaint.

Phone interview with Staff J, a physician, conducted on 09/26/19 at 9:56 AM revealed she was on duty the evening of September 6th and was not aware of the incident until ten minutes ago, when the medical director informed her of the situation.

Phone interview Staff M, a Physician Assistant on duty the evening of September 6th, conducted on 09/26/19 at 12:30 PM revealed he had no knowledge of the incident then or now.

Phone interview with Staff K, a Paramedic conducted on 09/26/19 at 11:44 AM revealed she was working on the triage area the evening of September 6th, it was busy night and something was going on outside with security and the patient care technician. Staff K went outside to assist with the situation and recalls how much the patient's mother wanted the son to be checked out and the charge nurse told him, they couldn't ' treat him unless he comes inside. The mother asked for the patient to be restrained and the nurse explained we could not do so. Then, she asked the charge nurse if he needed further assistance from her, he nodded no, and she return to the ED.


Phone interview with Staff N, a Patient Care Technician, conducted on 09/26/19 at 12:37 PM revealed she arrived at the incident right after the charge nurse and only recalls the patient's mother saying we are leaving, she said if you can't treat him, I will take him to another hospital.


Review of the electronic clinical records conducted on 09/25/19 provides no documented evidence that patient #21 was provided stabilizing treatment on 09/06/19 when he presented to the hospital's parking lot and request was made on his behalf requesting/seeking medical treatment.


Facility policy titled EMTALA Patient Presentation within 250 yards of Main Building or Directly to Emergency Department, effective 08/05/19 documents "To ensure that any patient on the hospital campus as defined in Administrative policy 01.23-2. Emergency Medical Services 250-yard rule revealed in part, "If an emergency medical condition exists, the patient will be stabilized, or the patient should be transferred to another acute care facility secondary to services not provided or available at Martin or lack of capacity."

The facility failed to ensure that Patient #21 was brought into the hospital's emergency department for treatment on 9/6/2019. As the hospital was equipped with such staff , services or equipment necessary to stabilize patient #21 on 9/6/2019.