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.

ORLANDO HEALTH 52 W UNDERWOOD ST ORLANDO, FL 32806 Oct. 2, 2019
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of Emergency Medical Services (EMS) documentation, hospital policies, Code of Conduct, video footage, "Event Summary with all Tasks," and interviews, the facility failed to provide a medical screening examination, and arrange for an appropriate transfer for 1 of 20 sampled patients (Patient #1).

Findings:

Cross Reference to A2406: The facility failed to provide a medical screening examination for 1 of 20 sampled patients that presented to the Emergency Department for treatment, (Patient #1).

Cross Reference to A2409: The facility failed to arrange an appropriate transfer for 1 of 20 sampled patients that presented to the Emergency Department for evaluation and treatment, (Patient #1).
VIOLATION: HOSPITAL MUST MAINTAIN RECORDS Tag No: A2403
Based on interview and review of Emergency Medical Services documentation, facility "Event Summary with All Tasks", review of "Corporate Emergency Department (ED): Documentation", review of video footage, review of Medical Staff Rules and Regulations, and review of patient #1's medical record, the facility failed to ensure the maintenance of a medical record of an individual transferred to another hospital for 1 of 20 sampled patients (Patient #1).

Findings:

A review of Emergency Medical Services (EMS) documentation from the City of Kissimmee Fire Department (FD) for 9/17/19 concerning patient #1 revealed the following. The patient was assessed by Kissimmee Fire Department EMS at 9/17/19 at 9:14 PM. EMS staff wrote, "Pt (patient) was able to ambulate to the stretcher and was secured and placed in the rescue with out incident. Pt stated that he had pain all over and rated the pain a 10 and stated that it felt like a pressure. Pt stated that he was to be transported to Orlando Health Osceola once on an ORO (EMS terminology)....I was notified that this pt was brought here (Orlando Health Dr. P Phillips Hospital) before and they stated that he was a psych pt and asked us to take him to a different location....Pt was transported to [another ED in Kissimmee]. EMS deemed the patient to require treatment in an ED to address medical concerns, the patient was taken to the facility, and subsequently taken to another hospital."

Additional EMS documentation at 1:11 PM on 9/20/19 (three days later) read, "Once at Orlando Health Osceola I was speaking with registration when the doctor on scene stated that the pt had been there before and that he is a psych pt....I asked him what I should do in the ER hallway and he asked me to transport the pt to a different hospital. I notified dispatch that we will be diverting to [another ED in Kissimmee]." This EMS documentation confirms that the patient had actually entered the ED, that the ED physician was directly aware of the patient's presence, and that the patient was taken from the facility's ED to another ED.

A review of available video footage from two cameras of the patient's presentation in the ED was performed on 9/30/19 at approximately 3:40 PM. It revealed the following as having taken place on 9/17/19. The view of the ambulance entrance showed the patient being brought into the ED by three EMS staff members at 9:26:06 AM. The remaining events were captured by a different camera which looked down a hallway at showed a nurses' station in the distance, on the right. The patient came into view in the hallway at 9:26:17 AM; he was taken to the vicinity of the nurses' station by EMS staff. The patient arrived to the vicinity of the nurses' station at 9:26:29 AM. The patient was taken into a room across from the nurses' station at 9:27:31 AM. At 9:27:50 AM, the ED physician arrived at the door to this room with a scribe and is seen talking into the room. At 9:28:23, the ED physician is seen walking away from the nurses' station. At 9:28:53 AM, the ED physician was seen walking back to the vicinity of the nurses' station, where he spoke with primarily one EMS staff member. At 9:29:22 AM, the ED physician is seen walking away. At 9:29:38 AM, EMS removed the patient from the room he was in, still on the gurney, and began to exit the ED. Thus, there was visual evidence that EMS delivered the patient into an ED room; the ED physician was aware of the patient's presence; the ED physician interacted with EMS staff, EMS removed the patient from the room and left the facility.

A review of the "Event Summary with all Tasks" written by the ED Operations Manager on 9/23/19 at 9:52 AM (referencing 9/17/19 at 9:30 PM) began with a statement by an ED registered nurse (RN) who witnessed events of patient #1's brief stay. He wrote: "On September 17 at 9:25 PM EMS Fire Rescue 14 Kissimmee arrive to the OFSED with an Psych and aggressive patient.... As soon as they enter patient to room 7, (the ED physician) came from another room and ask the medic what is the history of the patient. EMS explain to (the ED physician) the patient has a psych history and has been aggressive since they pick him on scene....EMS leave the ER at 09:29 PM with the patient to another facility...." The "Event Summary with all Tasks" written by the ED physician read, "Hi, so today again we had another EMS transport of a guy who looked acutely psychotic. Found him outside of 7/11 he was roughly 300 pounds saying obvious schizophrenic or drug related verbiage. Punching the air yelling. EMS was very nice when I pointed out that he seemed acute psychotic and aggressive. They acknowledged it. We never registered him and they apologized and took him to another facility. He did not look medically ill just acutely psychotic and aggressive and seemed to be a threat to our staff." The ED physician discussed patient #1 with EMS staff, stated that he visualized the patient and interacted with EMS staff, confirmed that the patient was taken to another hospital, and confirmed that the patient was not registered.

Registration would be necessary for the placement of the patient's name on the ED log.

During an interview of the ED physician on 10/1/19 at 11:20 AM, he stated that the patient arrived via EMS. EMS stated that they believed the patient's issue was psych related. He stated that he did not recall EMS mentioning any medical issues. He asked the patient how he was doing. The patient responded by punching up with both hands into the air and yelled with an aggressive tone "Are you a rookie?" He stated that the patient had an unusual stare and that he appeared to be aggressive, and believed him to be psychotic. He stated that he told EMS that they have to be careful about bringing aggressive patients here. He stated that an EMS staff member said, "Oh yes, I did get an email about this. I will take this patient somewhere else." He stated that EMS subsequently left the facility. He stated that since EMS said they would take the patient somewhere else, he did not consider the patient to have been accepted in the ED. He stated that therefore, there was no medical record and no formal transfer documentation. The ED physician admitted in interview that he interacted with EMS staff and the patient, and that the patient was subsequently transferred to another hospital.

During an interview of the Patient Access Representative on 10/01/19 at 2:15 PM, he stated that patient #1 arrived via ambulance. He stated that in order to register a patient, they needed a name, date of birth and social security number (or address). If all of these components are not available, they need to create an account. He stated that he was only able to get part of a name. He stated that everybody was talking when the patient was brought in (EMS & others). He stated that he is usually the last person to meet with a patient and that he generally waits for others to finish their discussions. He stated that the patient was not responsive to him concerning demographic information. He stated that he tried to get information from the paramedics, but they did not have enough information on the patient. He stated that he stood aside while the physician spoke to EMS. Thus, the Patient Access Representative stated that he was not able to secure the information which would have been needed to generate an account for the patient.

During an interview of the Risk Manager on 10/01/19 at 3:10 PM, she confirmed that as of 9/30/19, there had been no correction the emergency room Log to show that the patient had presented and no late-entry creation of a medical record to also reflect that the patient had been in the facility on 9/17/19. At 3:43 PM, she stated that a patient's name will automatically appear on the log when an account is created, and that the creation of an account will enable the creation of a medical record.

Facility document "Corporate ED: Documentation", which was applicable to nursing, read, "All registered patients are assessed at onset of care and throughout their visit. Documentation is completed in real time; however, when not possible ensure that the time marked is reflective of the time the treatment was rendered." Since the patient was never registered, this requirement for medical record documentation could not be fulfilled. There was no documentation to confirm whether or not any activity took place with the patient who had been taken inside the Emergency Department.

A review of Medical Staff Rules and Regulations read, "Each medical staff member shall be responsible for the preparation of a complete and legible record for each patient." There was no documentation that showed ED physician compliance with this requirement.

During an interview of the Risk Manager at approximately 2:45 PM on 10/2/19, she confirmed that there had been no correction of the emergency room Log to show that the patient had presented, and no late-entry creation of a medical record to also reflect that the patient had been in the facility on 9/17/19.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on review of Emergency Medical Services documentation, facility "Event Summary with All Tasks", review of video footage, and interviews, the facility failed to ensure the maintenance of a central log on each individual who presented to the emergency department (ED) requesting emergency services for 1 of 20 sampled patients (Patient #1).

Findings:

A review of Emergency Medical Services (EMS) documentation from the City of Kissimmee Fire Department (FD) for 9/17/19 concerning patient #1 revealed the following. The patient was assessed by Kissimmee FD EMS on 9/17/19 at 9:14 PM. EMS staff wrote, "Pt (patient) was able to ambulate to the stretcher and was secured and placed in the rescue with out incident. Pt stated that he had pain all over and rated the pain a 10 and stated that it felt like a pressure. Pt stated that he was to be transported to Orlando Health Osceola once on an ORO (EMS terminology)....I was notified that this pt was brought here (Orlando Health Dr. P Phillips Hospital) before and they stated that he was a psych pt and asked us to take him to a different location....Pt was transported to [another ED in Kissimmee]. Thus, the EMS deemed the patient to require treatment in an ED to address medical concerns, was taken to the facility, and subsequently taken to another hospital.

EMS documentation entered at 1:11 PM on 9/20/19 (three days later) read, "Once at Orlando Health Osceola I was speaking with registration when the doctor on scene stated that the pt had been there before and that he is a psych pt.... I asked him what I should do in the ER hallway and he asked me to transport the pt to a different hospital. I notified dispatch that we will be diverting to [another ED in Kissimmee]." This part of EMS documentation confirms that the patient had actually entered the ED and that the ED physician was directly aware of the patient's presence. It further testifies to the patient being taken from the facility's ED to another ED.

A review of available video footage from two cameras of the patient's presentation in the ED was performed on 9/30/19 at approximately 3:40 PM. It revealed the following as having taken place on 9/17/19. The view of the ambulance entrance showed the patient being brought to the ED by three EMS staff members at 9:26:06 AM. The patient was taken into a room across from the nurses' station at 9:27:31 AM. At 9:27:50 AM, the ED physician arrived at the door to this room with a scribe and is seen talking into the room. At 9:28:23, the ED physician is seen walking away from the nurse's station. At 9:29:38 AM, EMS removed the patient from the room he was in, still on the gurney, and began to exit the ED. There was visual evidence that EMS delivered the patient into an ED room; the ED physician was aware of the patient's presence; the ED physician interacted with EMS staff ,and EMS removed the patient from the room and left the facility.

A review of the "Event Summary with all Tasks" written by the ED Operations Manager on 9/23/19 at 9:52 AM (referencing 9/17/19 at 9:30 PM) began with a statement by an ED registered nurse (RN) who witnessed events of patient #1's brief stay. He wrote, "On September 17 at 9:25 PM, EMS Fire Rescue 14 Kissimmee arrive to the OFSED with an Psych and aggressive patient.... As soon as they enter patient to room 7 (the ED physician) came from another room and ask the medic what is the history of the patient. EMS explain to (the ED physician) the patient has a psych history and has been aggressive since they pick him on scene....EMS leave the ER at 09:29 AM with the patient to another facility." Thus, the ED physician discussed patient #1 with EMS staff, and confirmed that the patient was taken away for transport to another facility. The "Event Summary with All Tasks" written by the ED physician read, "Hi, so today again we had another EMS transport of a guy who looked acutely psychotic. We never registered him, they apologized and took him to another facility. He did not look medically ill just acutely psychotic and aggressive and seemed to be a threat to our staff." Thus the Emergency Department physician stated that he visualized the patient, interacted with EMS staff, confirmed that the patient was taken to another hospital, and confirmed that the patient was not registered.

Registration would be necessary for the placement of the patient's name on the ED log and the subsequent creation of a medical record.

During an interview of the ED physician on 10/01/19 at 11:20 AM, he stated that the patient arrived via EMS. EMS stated that they believed the patient's issue was psych related. He stated that he did not recall EMS mentioning any medical issues. He stated that EMS subsequently left the facility. He stated that since EMS said they would take the patient somewhere else, he did not consider the patient to have been accepted in the ED. He stated that therefore, there was no medical record and no formal transfer documentation. Thus, the ED physician admitted in interview that he interacted with EMS staff and the patient, and that the patient was subsequently transferred to another hospital. This confirms that the patient was brought into the ED by EMS, that there was interaction between the ED physician and both the patient and EMS staff, and that the patient was subsequently taken from the ED to another hospital.

During an interview of the Patient Access Representative on 10/01/19 at 2:15 PM, he stated that patient #1 arrived via ambulance. He stated that in order to register a patient, they needed a name, date of birth and social security number (or address). If all of these components are not available, they need to create an account. The Patient Access Representative admitted that he was not able to secure the information which would have been needed to generate an account for the patient.

On 10/01/19 at 3:10 PM, the Risk Manager confirmed that as of 9/30/19, there had been no correction on the emergency room Log to show that the patient had presented. At 3:43 PM, she stated that a patient's name will automatically appear on the log when an account is created. She stated that the creation of an account will enable the creation of a medical record.

On 10/02/19 at approximately 2:45 PM, the Risk Manager confirmed that there had been no correction on the emergency room Log to show that the patient had presented.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on review of Emergency Medical Services documentation, video footage, "Event Summary with all Tasks", and interview, the facility failed to provide a medical screening examination for 1 of 20 sampled patients that presented to the Emergency Department (ED) for treatment, (Patient #1).

Findings:

A review of Emergency Medical Services (EMS) documentation from the City of Kissimmee Fire Department for 9/17/19 concerning patient #1 revealed the following. The patient was assessed by Kissimmee Fire Department (FD) EMS at 9/17/19 at 9:14 PM. EMS staff wrote: "Pt (patient) was able to ambulate to the stretcher and was secured and placed in the rescue with out incident. Pt stated that he had pain all over and rated the pain a 10 and stated that it felt like a pressure." The entry continued: "I was notified that this pt was brought here (Orlando Health Dr. P Phillips Hospital) before and they stated that he was a psych pt and asked us to take him to a different location." The entry continued: "Pt was transported to [another ED in Kissimmee]."

Additional EMS documentation entered at 1:11 PM on 9/20/19 (three days later) read, "Once at Orlando Health Osceola I was speaking with registration when the doctor on scene stated that the pt had been there before and that he is a psych pt.... I asked him what I should do in the ER hallway and he asked me to transport the pt to a different hospital. I notified dispatch that we will be diverting to [another ED in Kissimmee]." This part of EMS documentation confirmed that the patient had actually entered the ED, that the ED physician was directly aware of the patient's presence, and that the patient was taken from the facility's ED to another ED.

A review of available video footage from two cameras of the patient's presentation in the ED was performed on 9/30/19 at approximately 3:40 PM. It revealed the following as having taken place on 9/17/19. The view of the ambulance entrance showed the patient being brought into the ED by three EMS staff members at 9:26:06 AM. The patient came into view in the hallway at 9:26:17 AM. At 9:27:50 AM, the ED physician arrived at the door to the room with a scribe and is seen talking into the room. At 9:28:23, the ED physician is seen walking away from the nurses' station. At 9:28:53 AM, the ED physician was seen walking back to the vicinity of the nurses' station, where he spoke with primarily one EMS staff member. At 9:29:22 AM, the ED physician is seen walking away. At 9:29:38 AM, EMS removed the patient from the room he was in, still on the gurney, and began to exit the ED. There was visual evidence that EMS delivered the patient into an ED room; the ED physician was aware of the patient's presence; the ED physician interacted with EMS staff, and EMS removed the patient from the room and left the facility.

A review of the "Event Summary with all Tasks", written by the ED Operations Manager on 9/23/19 at 9:52 AM (referencing 9/17/19 at 9:30 PM), revealed the following, which began with a statement by an ED registered nurse (RN) who witnessed events of patient #1's brief stay. He wrote, "On September 17 at 9:25 PM, EMS Fire Rescue 14 Kissimmee arrive to the OFSED with a Psych and aggressive patient.... As soon as they enter patient to room 7, (the ED physician) came from another room and ask the medic what is the history of the patient. EMS explain to (the ED physician) the patient has a psych history and has been aggressive since they pick him on scene....EMS leave the ER at 09:29 PM with the patient to another facility." Thus, the ED physician discussed patient #1 with EMS staff, and confirmed that the patient was taken away for transport to another facility. The "Event Summary with All Tasks" document with text authored by the ED physician read, "Hi, so today again we had another EMS transport of a guy who looked acutely psychotic. Found him outside of 7/11 he was roughly 300 pounds saying obvious schizophrenic or drug related verbiage. Punching the air yelling. EMS was very nice when I pointed out that he seemed acute psychotic and aggressive. They acknowledged it. We never registered him and they apologized and took him to another facility. He did not look medically ill just acutely psychotic and aggressive and seemed to be a threat to our staff." The ED physician stated that he visualized the patient and interacted with EMS staff. He confirmed that the patient was taken to another hospital. He also confirmed that the patient was not registered.

During an interview of the ED physician on 10/01/19 at 11:20 AM, he stated the patient arrived via EMS. EMS stated that they believed the patient's issue was psych related. He stated that he did not recall EMS mentioning any medical issues. He asked the patient how he was doing. The patient responded by punching up with both hands into the air and yelled with an aggressive tone "Are you a rookie?" He stated that the patient had an unusual stare and appeared to be aggressive. He stated that he believed him to be psychotic. He stated that he told EMS that they have to be careful about bringing aggressive patients here. He stated that an EMS staff member said, "Oh yes, I did get an email about this. I will take this patient somewhere else." He stated that EMS subsequently left the facility. He stated that since EMS said they would take the patient somewhere else, he did not consider the patient to have been accepted in the ED. He stated that therefore, there was no medical record and no formal transfer documentation. Thus, the ED physician admitted in interview that he interacted with EMS staff and the patient, and that the patient was subsequently transferred to another hospital.

The evidence confirmed that the patient was brought to the ED by EMS, that there was interaction between the ED physician, the patient and EMS staff, and that the patient was subsequently taken from the ED to another hospital without a medical screening examination being performed or documented.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on review of Emergency Medical Services, video footage, "Event Summary with all Tasks", hospital policy titled, "Transfer Process for Patients to another Acute Care Facility", "Code of Conduct", and interview, the facility failed to arrange an appropriate transfer for 1 of 20 sampled patients (Patient #1).

Findings:

A review of Emergency Medical Services (EMS) documentation from the City of Kissimmee Fire Department for 9/17/19 concerning patient #1 revealed the following. The patient was assessed by Kissimmee Fire Department (FD) EMS at 9/17/19 at 9:14 PM. EMS staff wrote: "Pt (patient) was able to ambulate to the stretcher and was secured and placed in the rescue with out incident. Pt stated that he had pain all over and rated the pain a 10 and stated that it felt like a pressure. Pt stated that he was to be transported to Orlando Health Osceola once on an ORO (EMS terminology)." Thus, the EMS deemed the patient to require treatment in an Emergency Department (ED) to address medical concerns. The entry continued: "I was notified that this pt was brought here (Orlando Health Dr. P Phillips Hospital) before and they stated that he was a psych pt and asked us to take him to a different location." The entry continued: "Pt was transported to [another ED in Kissimmee]."

Additional EMS documentation entered at 1:11 PM on 9/20/19 (three days later) read, "Once at Orlando Health Osceola I was speaking with registration when the doctor on scene stated that the pt had been there before and that he is a psych pt.... I asked him what I should do in the ER hallway and he asked me to transport the pt to a different hospital. I notified dispatch that we will be diverting to [another ED in Kissimmee]." This part of EMS documentation confirmed that the patient had actually entered the ED, that the ED physician was directly aware of the patient's presence, and that the patient was taken from the facility's ED to another ED.

A review of available video footage from two cameras of the patient's presentation in the ED was performed on 9/30/19 at approximately 3:40 PM. It revealed the following as having taken place on 9/17/19. The view of the ambulance entrance showed the patient being brought into the ED by three EMS staff members at 9:26:06 AM. The patient was taken into a room across from the nurses' station at 9:27:31 AM. At 9:27:50 AM, the ED physician arrived at the door to this room with a scribe and is seen talking into the room. At 9:28:23, the ED physician is seen walking away from the nurses' station. At 9:28:53 AM, the ED physician was seen walking back to the vicinity of the nurses' station, where he spoke with primarily one EMS staff member. At 9:29:22 AM, the ED physician is seen walking away. At 9:29:38 AM, EMS removed the patient from the room he was in, still on the gurney, and began to exit the ED. There was visual evidence that EMS delivered the patient into an ED room; the ED physician was aware of the patient's presence; the ED physician interacted with EMS staff, and EMS removed the patient from the room and left the facility.

A review of the "Event Summary with all Tasks", written by the ED Operations Manager on 9/23/19 at 9:52 AM (referencing 9/17/19 at 9:30 PM), revealed the following, which began with a statement by an ED registered nurse (RN) who witnessed events of patient #1's brief stay. He wrote, "On September 17 at 9:25 PM, EMS Fire Rescue 14 Kissimmee arrive to the OFSED with a Psych and aggressive patient.... As soon as they enter patient to room 7, (the ED physician) came from another room and ask the medic what is the history of the patient. EMS explain to (the ED physician) the patient has a psych history and has been aggressive since they pick him on scene....EMS leave the ER at 09:29 PM with the patient to another facility." Thus, the ED physician discussed patient #1 with EMS staff, and confirmed that the patient was taken away for transport to another facility. The "Event Summary with All Tasks" document with text authored by the ED physician read, "Hi, so today again we had another EMS transport of a guy who looked acutely psychotic. Found him outside of 7/11 he was roughly 300 pounds saying obvious schizophrenic or drug related verbiage. Punching the air yelling. EMS was very nice when I pointed out that he seemed acute psychotic and aggressive. They acknowledged it. We never registered him and they apologized and took him to another facility. He did not look medically ill just acutely psychotic and aggressive and seemed to be a threat to our staff." The ED physician stated that he visualized the patient and interacted with EMS staff. He confirmed that the patient was taken to another hospital. He also confirmed that the patient was not registered.

During an interview of the ED physician on 10/01/19 at 11:20 AM, he stated the following. He stated that the patient arrived via EMS. EMS stated that they believed the patient's issue was psych related. He stated that he did not recall EMS mentioning any medical issues. He asked the patient how he was doing. The patient responded by punching up with both hands into the air and yelled with an aggressive tone "Are you a rookie?" He stated that the patient had an unusual stare and appeared to be aggressive. He stated that he believed him to be psychotic. He stated that he told EMS that they have to be careful about bringing aggressive patients here. He stated that an EMS staff member said, "Oh yes, I did get an email about this. I will take this patient somewhere else." He stated that EMS subsequently left the facility. He stated that since EMS said they would take the patient somewhere else, he did not consider the patient to have been accepted in the ED. He stated that therefore, there was no medical record and no formal transfer documentation. Thus, the ED physician admitted in interview that he interacted with EMS staff and the patient, and that the patient was subsequently transferred to another hospital.

The evidence confirmed that the patient was brought to the ED by EMS, that there was interaction between the ED physician, the patient and EMS staff, and that the patient was subsequently taken from the ED to another hospital.

A review of facility policy "Transfer Process for Patients to another Acute Care Facility" read, "It is the policy of Orlando Health that: The transfer of patients to acute care facilities complies with the regulations of the Emergency Medical Treatment and Labor Act (EMTALA).... Procedure: Emergency transfers: When an emergent transfer is requested for a patient going to another facility, call the Transfer Center....Documentation: As appropriate in the medical record (Orlando Health Consent Form #5961- , Patient Transfer Physician's Certification of Appropriateness of Transfer)." There was no documented evidence that a telephone call was placed to the Transfer Center and that the form "Patient Transfer Physician's Certification of Appropriateness of Transfer" was completed.

A review of the "Code of Conduct" read that, "Patients may only be transferred after they have been stabilized and are formally accepted by the alternate facility. EMTALA procedures must be followed."

During an interview of the Risk Manager on 10/01/19 at 3:40 PM, she confirmed that no call had been placed to the Transfer Center or transfer documentation completed concerning patient #1's visit to the ED on 9/17/19.

On 10/02/19 at approximately 2:45 PM, the Risk Manager confirmed that the hospital did not perform an appropriate transfer for Patient #1.