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.

LAKE BUTLER HOSPITAL 850 E MAIN ST LAKE BUTLER, FL 32054 April 30, 2020
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on video review, Emergency Central Log review, interviews, and observation, the ED (Emergency Department) failed to ensure an individual who comes to the Emergency Department was provided with an appropriate medical screening examination within the capability of the hospital's ED, including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition existed for 2 of 21 patients sampled, Patients #11 and #21.

Findings include:

Refer to findings in deficiencies cited under C-2406.
VIOLATION: POSTING OF SIGNS Tag No: C2402
Based on observation, interview, and policy and procedure review, the facility failed to ensure signs were posted in the emergency Department (ED) to notify patients of their right to a medical screening examination and stabilization treatment as required under EMTALA (Emergency Medical and Treatment Act and Labor Act).


Findings:

An observation of the Emergency Department on 04/30/2020 at 8:50 AM showed there were no signs posted in the Emergency Department specifying a patient has a right to a medical screening examination and stabilization treatment as specified under EMTALA as required, at a minimum, to specify the rights of individuals with an emergency medical condition and women in labor who come to the Emergency Department for health care services.

During an interview on 04/30/2020 at 8:55 AM with the Chief Nursing Officer (CNO), when asked the location of the EMTALA signage, she stated, "Patients have a right to a medical screening exam and stabilization treatment as specified by EMTALA; there are no signs posted to notify them of that right. We have been waiting for the laminated signs to be put up."

Review of the policy titled "Patient Care emergency room -Signage" approved on 02/1/2019 reads, "All facilities located on the property or premises which provide medical services must post appropriate signage notifying patients of their right to a medical screening examination and stabilization treatment as specified under EMTALA. The signage must provide at a minimum, that specific rights of patients with emergency conditions and women in labor. If you have a medical emergency or are in labor, even if you cannot pay or do not have medical insurance or not entitled to Medicare or Medicaid, you have the right to receive, within the capabilities of this hospital staff and facilities: An appropriate medical screening examination, necessary stabilizing treatment and an appropriate transfer to another facility."
VIOLATION: EMERGENCY ROOM LOG Tag No: C2405
Based on video review, Emergency Central Log review, incident report, policy and procedure review, and staff interviews, the facility failed to ensure a Central Log was maintained of each individual who came to the ED (Emergency Department) seeking assistance and failed to document the disposition of the patient for 2 of 21 sampled patients, Patients #11 and #21.

Findings:

Review of the facility video that was recorded by the camera positioned at the entry of the ED dated 3/17/2020 at 4:30 PM, showed Patient #11 on the video carrying a small child in her arm and had a second small child by the hand. Patient #11 was observed to press a button that was located on the wall to the patient's right. There was a staff member observed opening the door, who was later identified to be the Registrar. There was no audio available for the video. Patient #11 was observed leaving the area with her two small children.

Review of the Emergency Central Log for the period from 03/15/2020 at 12:00 AM to 03/20/2020 at 12:00 AM revealed there was no entry made in the log of Patient #11 having arrived at the ED seeking medical treatment.

Review of the incident report provided by the Risk Manger for Patient #11 revealed on 03/18/2020, the mother [Patient #11] came to the ED door with two children and stated they needed to be seen. The Registrar asked the COVID-19 screening questions. The mother said kids had fever and cough and had contact with large groups of people. The mother told the Registrar the children had an appointment with primary care in the morning. The mother said she gave the children Tylenol and Motrin and they were drinking plenty of fluids and eating well. The Registrar went to the clinician and was told by the clinician to tell the mother to continue to rotate Tylenol and Motrin, drink fluids, and to keep the appointment with the primary care provider.

Review of the facility video that was recorded by the camera positioned at the entry of the ED dated 04/10/2020 at 2:15 AM, showed a staff was triaging patients outside of the ED; taking vitals on an infant. The staff was observed to turn her head toward an older gentleman who was accompanying a minor child, Patient #21. The older gentleman was seen pointing his index finger toward the minor child who was sitting in a chair. Conversation was observed by the moving of lips by the older gentleman, then the older gentleman was observed walking with the minor child away from the ED entry toward a car in the parking lot.

Review of the Emergency Central Log for the period from 04/8/2020 at 12:00 AM to 04/13/2020 at 12:00 AM revealed there was no entry made in the log of Patient #21 having arrived at the ED seeking medical treatment.

Review of the incident report provided by the Risk Manager for Patient #21 revealed on 04/13/2020, the Registered Nurse (RN) covering the ED was triaging a patient outside ED entrance. She was taking vitals on an infant when she saw a man standing at the end of the ramp. The RN asked the man if he needed to be seen. He pointed to his daughter who was sitting in a chair and stating he needed to get her knee looked at. He stated It had been bothering her for a week, it went away, but it was bothering her again. The RN stated, "okay there will be a little bit of a wait as there are two patients ahead of you. You guys can wait, or you can contact your primary care physician." At that time, he became upset and stated, "oh so you are refusing us treatment." RN stated, "No, sir I didn't say that." RN was unsure if he heard her reply. He and his daughter continued walking toward the vehicle yelling he was going to call his attorney and the head of the hospital. The RN again stated. "Sir, we are not refusing to see your daughter." The man continued to his vehicle and they drove off. The RN advised the clinician of the above circumstances.

During an interview on 04/30/2020 at 1:15 PM, the Risk Manager confirmed that Patients #11 and #21 should have been added to the Emergency Central Log.

Review of the facility's policy titled "Patient Care emergency room -Central Log" approved on 02/01/2020 read, "To track the care provided to everyone who comes to the hospital property or premises seeking care for an emergency medical condition. The log will contain, whether the individual refused treatment, was refused treatment, transferred, admitted and treated, stabilized and transferred or discharge. A log entry should be made at the first point of contact. This would normally take place at triage and be finalized after the medical screening and or any necessary treatment and stabilization to address the emergency medical condition."
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
Based on Emergency Central Log review, policy and procedures review, and interview, the facility failed to ensure individuals who came to the ED (Emergency Department) were provided with an appropriate medical screening examination within the capability of the hospital ED, to determine whether or not an emergency medical condition existed for 2 of 21 sampled patients, Patients #11 and #21.

Findings:

Review of facility's policy and procedure titled "Patient Care-emergency room Medical Screening" approved on 02/01/2019 read, "Purpose: To ensure that all patients who come to the dedicated ED requesting emergency services receive an appropriate Medical Screening Examination as required by EMTALA [Emergency Medical Treatment and Labor Act] and all Federal regulations and interpretive guidelines. Policy: Any individual who come to the dedicated emergency department requesting an examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by an individual qualified to perform such examination to determine whether an emergency medical condition exists. On Page 5 Under E number 1: There shall be no delay in providing a Medical Screening Examination or follow-up treatment for an emergency medical condition in order to inquire about patient's method of payment. On page 6, numbered 6: If a patient withdraws his/her request for examination and treatment or refuses further examination or treatment, an appropriate trained individual from the ED staff will discuss the medical issues related to a voluntary withdrawal. A: offer patient further medical examination and treatment as may be required to identify and stabilize an emergency medical condition. B. Inform the patient of the benefits or the examination and treatment as may be required to identify and stabilize an emergency condition."

Review of facility's policy and procedure titled "EMTALA access of Emergency Care and Treatment" approved on 02/01/2020 read, "Purpose: To assure that all patients on hospital property who request an examination and treatment for a medical condition shall have that examination and care regardless of insurance coverage/ability to pay."

Review of the facility's policy and procedure titled "EMTALA-No Delay in Screening Examination" approved on 02/01/2019 read, "Purpose: To assure that medical screening and/or medical treatment are not delayed inquiring about insurance. Special instructions: Patients presenting for treatment/care shall immediately be triaged to determine the severity of their illness and the order in which they will be treated. Patients shall be given a medical screening and if an emergency condition is found they shall be provided the treatment and care required for stabilization as far as the hospital space, supplies, equipment and medical specialist allow. If further treatment care is required, that this hospital cannot provide, a transfer to another facility shall be made."

Review of the facility video that was recorded by the camera positioned at the entry of the ED dated 3/17/2020 at 4:30 PM, showed Patient #11 on the video carrying a small child in her arm and had a second small child by the hand. Patient #11 was observed to press a button that was located on the wall to the patient's right. There was a staff member observed opening the door, who was later identified to be the Registrar. There was no audio available for the video. Patient #11 was observed leaving the area with her two small children.

Review of the Emergency Central Log for the period from 03/15/2020 at 12:00 AM to 03/20/2020 at 12:00 AM revealed there was no entry made in the log of Patient #11 having arrived at the ED seeking medical treatment.

Review of the incident report provided by the Risk Manger for Patient #11 revealed on 03/18/2020, the mother [Patient #11] came to the ED door with two children and stated they needed to be seen. The Registrar asked the COVID-19 screening questions. The mother said kids had fever and cough and had contact with large groups of people. The mother told the Registrar the children had an appointment with primary care in the morning. The mother said she gave the children Tylenol and Motrin and they were drinking plenty of fluids and eating well. The Registrar went to the clinician and was told by the clinician to tell the mother to continue to rotate Tylenol and Motrin, drink fluids, and to keep the appointment with the primary care provider.

Review of the facility video that was recorded by the camera positioned at the entry of the ED dated 04/10/2020 at 2:15 AM, showed a staff was triaging patients outside of the ED; taking vitals on an infant. The staff was observed to turn her head toward an older gentleman who was accompanying a minor child, Patient #21. The older gentleman was seen pointing his index finger toward the minor child who was sitting in a chair. Conversation was observed by the moving of lips by the older gentleman, then the older gentleman was observed walking with the minor child away from the ED entry toward a car in the parking lot.

Review of the Emergency Central Log for the period from 04/8/2020 at 12:00 AM to 04/13/2020 at 12:00 AM revealed there was no entry made in the log of Patient #21 having arrived at the ED seeking medical treatment.

Review of the incident report provided by the Risk Manager for Patient #21 revealed on 04/13/2020, the Registered Nurse (RN) covering the ED was triaging a patient outside ED entrance. She was taking vitals on an infant when she saw a man standing at the end of the ramp. The RN asked the man if he needed to be seen. He pointed to his daughter who was sitting in a chair and stating he needed to get her knee looked at. He stated It had been bothering her for a week, it went away, but it was bothering her again. The RN stated, "okay there will be a little bit of a wait as there are two patients ahead of you. You guys can wait, or you can contact your primary care physician." At that time, he became upset and stated, "oh so you are refusing us treatment." RN stated, "No, sir I didn't say that." RN was unsure if he heard her reply. He and his daughter continued walking toward the vehicle yelling he was going to call his attorney and the head of the hospital. The RN again stated. "Sir, we are not refusing to see your daughter." The man continued to his vehicle and they drove off. The RN advised the clinician of the above circumstances.

During an interview on 04/30/2020 at 1:15 PM, the Risk Manager confirmed that Patients #11 and #21 should have been added to the Emergency Central Log in order for an Medical screening exam to be done.