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 Oct. 27, 2020
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on interviews and facility document review, the hospital failed to ensure that each individual presenting to the emergency department and requesting services was provided a Medical Screening Examination for 1 of 20 patients presenting to the Emergency Department (Patient #20). The hospital failed to provide triage or medical screening services for Patient #20 on 10/12/2020 upon presentation to the Emergency Department following a failed suicide attempt.

The findings include:

Refer to A2406 for findings.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interviews, patient medical record reviews and facility document review, the facility failed to ensure that each individual presenting to the emergency department, and requesting services was maintained on the Emergency Department's Control Registry log for 1 of 20 patients presenting to the Emergency Department. (Patient #20)

The findings include:

On 10/22/20 at 2:00 PM, a telephone interview was conducted with three managers at Patient #20's residential mental health treatment provider. They expressed concern regarding one of their adolescent patients, #20, who accompanied by her mother, was reportedly brought to the hospital on [DATE] secondary to a failed suicide attempt. The staff stated the patient's mother had call the Mobile Health Response Team (MRT) and reported the attempted suicide and they advised she take her daughter to the hospital for a medical evaluation and Baker Act admission. On 10/12/20 the mother again contacted the MRT and reported the hospital had declined to see her daughter.

On 10/26/2020 a review of the hospital Emergency Department Control Registry log for 10/12/2020 was reviewed. The log failed to include Patient #20.

A review of the facility's October 2020 Emergency Medical Services Log and Emergency Department Transfer Out log, failed to identify Patient #20.

On 10/26/2020 at approximately 12:20 PM, an interview was conducted with the Director of the Emergency Department, a Registered Nurse. The Director stated that she had been alerted, after receiving a call from the Baker Act Coordinator, of concerns in which a patient presented to the Emergency Department (ED) and did not get seen. The Director of the ED stated she did not know the patient's name, but she did some investigation and determined the patient never presented to the Emergency Department. She stated she thinks that the MRT (Mobile Response Team) called the Sheriff's department and the patient was transported to Fort Walton Beach Medical Center. She did not document or complete an incident report; but had left a message for the Risk Manager and had planned to speak with her today about it.

On 10/26/2020 at approximately 12:45 PM, a telephone interview was conducted with Patient #20's mother. Patient #20's mother described the events that led up to the visit to the ED on 10/12/2020. The mother stated that after seeking the advice from her daughter's psychiatrist she was advised to call 911, to have her daughter transported to Twin Cities for a medical evaluation and Baker Act. The mother described that Patient #20 rode in the police car and she followed in her own car. The mother stated they went inside to the ED and she was handed a form which she began to complete, as she explained to the girl at the front desk that her daughter needed to be seen and Baker Acted because she had attempted to hang herself. The mother said that the girl in the ED told her "we don't handle Baker Acts," and that if they wanted "her admitted it might be 3 days before someone got to them." She did not complete the registration form. She said, she was upset that it was taking so long. She didn't know what else to do, so she indicated they left the emergency room .

On 10/26/2020 at approximately 1:15 PM, an interview was conducted with Staff Member D, an Emergency Medical Technician, who works the registration desk in the Emergency Department (ED). Staff Member D recalled the mother and Patient #20 coming into the ED waiting room, accompanied by Staff Member F. Staff Member D stated that the mother came to the desk demanding her daughter be seen and that she needed to be admitted for Baker Act. Staff Member D stated she told the mother that they 'don't admit Baker Acts' and we 'could not see her as quickly' as she was asking (snapping her fingers), she stated to the mother that' it might be 3-5 days before she is seen (by psych.)' Staff Member D did not recall any unusual observations of Patient #20 and did not recall if the mother had started any paperwork. Staff Member D stated that when a patient comes into the ED, she timestamps the "EMTALA Sign-in Sheet," and hands the form to the patient or patient representative to complete. Staff Member D did not retain any documentation and stated the form would have been shredded. Staff Member D stated she informed the Charge Nurse.

On 10/26/2020 at approximately 1:20 PM, the Director of the Emergency Department was interviewed regarding her investigation. She stated she called and spoke with the physician on duty that night, and he was not aware of any occurrence. The Director stated she interviewed the one desk person, Staff Member E, who worked 6:00 PM-6:00 AM, because he would have been the only person to have had interaction with the patient and/or the mother, and there was no indication that she (Patient #20) had been seen. She stated she also interviewed Staff Member B, the Charge Nurse, who was on-duty that night and he had no recollection of the patient or mother. She did not interview anyone else because she thought the event had occurred after 6:00 PM. The Director stated she would expect anyone that presented to the Emergency Department requesting to be seen should be documented on the Emergency Department's Control Registry Log and a Medical Screening examination performed. If a patient did not want to sign in, she would still expect an admission form be completed or a form indicating they left prior to being triaged (LPT).

On 10/26/2020 at approximately 1:35 PM, an interview was conducted with Staff Member F. Staff Member F stated she was doing COVID-19 (Coronavirus Disease 2019) screening at the main entrance when Patient #20 and her mother came in. She stated it was around 5:50 PM, because it was near the end of her shift. She stated she performed COVID-19 screening on both the mother and daughter when she said the mother stated she needed the Emergency Department and that her daughter had tried to kill herself, she said she noticed marks around the daughter's neck. She didn't want the mother and Patient #20 to have to walk around the building to the ED, so she escorted them through the building to the ED and handed them off to Staff Member D telling the mother and daughter to have a seat at the window. She didn't think anything further about it, until she was leaving the building when she noticed the mother and daughter were walking back towards the front of the hospital - says it was roughly 20-25 minutes later. She says, she 'thought this was odd that they were walking in the parking lot' and had even mentioned this to a co-worker the next day. She did not report her concerns to anyone else.

On 10/26/2020 at 5:10 PM, a telephone interview was conducted with Staff Member B, a Registered Nurse and the Charge Nurse in the Emergency Department the night of 10/12/2020. Staff Member B stated he recalled Staff Member D coming to him at shift changes a few weeks ago and telling him there was a lady and her daughter in the waiting room and that the mother wanted her admitted for Baker Act. He stated he told Staff Member D, "of course we'll see her and go ahead and sign her in." He stated he never got the paperwork so he thought the mother must have changed her mind. During a second telephone interview on 10/27/2020 at 9:15 AM, Staff Member B stated he remembered asking about the mother and daughter awhile later and was told they went to Fort Walton Beach Medical Center. Staff Member B did not recall who told him this.

On 10/27/2020 at 08:45 AM the Risk Manager, who had just been alerted to the occurrence on 10/26/2020, stated she was able to view the video footage that described the following timeline:
- 5:46 PM - The mother's car and police car pull into the front parking lot, the mother parks her car. Patient #20 is in the police vehicle.
- 5:50 PM The police vehicle leaves Patient #20 at her mother car and they both entered into the main entrance of the hospital.
- 5:52 PM - Staff Member F is observed walking in the hallway with the mother and Patient #20, towards the Emergency Department.
- 6:09 PM - The mother and Patient #20 can be seen leaving the Emergency Department walking back towards the front of the hospital.
- 6:28 PM - The mother and Patient #20 are sitting under canopy on bench.
- 6:49 PM - An unidentified man arrives; Patient #20 is seen hugging the man.
- 6:47 PM - A Mental Health Resource (MHR) person arrives
- 7:02 PM - The 3 females (Mother, Patient #20 and MHR person) walk around back to the Emergency Department and enter the Emergency Department waiting room.
- 7:10 PM - The 3 females exit the Emergency Department
- 7:11 PM - Sheriff arrives. He parks his car and comes down to talk to the mother and patient. Paperwork is exchanged.
- 7:17 PM - Mom and daughter walk to the Sheriff's car.
- 7:22 PM - Mother walks back to the MHR person. Patient #20 is in the Sheriff's vehicle.
- 7:26 PM - Sheriff leaves with Patient #20.
- 8:09 PM - The mother and unidentified man leave.

The hospital has construction underway in the Emergency Department and stated there was no footage in the Emergency Department waiting room.

A review of the facility's policy and procedure entitled, "EMTALA (Emergency Medical Treatment and Labor Act) - Central Log (HCA Florida Specific Model Policy,) last updated on February 1, 2016 indicates, "The hospital will maintain a Central log containing information on each individual who requests emergency services or care or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examine ("MSE") could be performed, whether he or she refused treatment, whether he or she was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged .
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews and facility document review, the hospital failed to ensure that each individual presenting to the emergency department and requesting services was provided a Medical Screening Examination for 1 of 20 patients presenting to the Emergency Department (Patient #20). The hospital failed to provide triage or medical screening services for Patient #20 on 10/12/2020 upon presentation to the Emergency Department following a failed suicide attempt.

The findings include:

On 10/22/20 at 2:00 PM, a telephone interview was conducted with three managers at Patient #20's residential mental health treatment provider. They expressed concern regarding one of their adolescent patients, #20, who accompanied by her mother, was reportedly brought to the hospital on [DATE] secondary to a failed suicide attempt. The staff stated the patient's mother had call the Mobile Health Response Team (MRT) and reported the attempted suicide and they advised she take her daughter to the hospital for a medical evaluation and Baker Act admission. On 10/12/20 the mother again contacted the MRT and reported the hospital had declined to see her daughter.

On 10/26/2020 a review of the hospital Emergency Department Control Registry log for 10/12/2020 was reviewed. The log failed to include Patient #20.

A review of the facility's October 2020 Emergency Medical Services Log and Emergency Department Transfer Out log, failed to identify Patient #20.

On 10/26/2020 at approximately 12:20 PM, an interview was conducted with the Director of the Emergency Department, a Registered Nurse. The Director stated that she had been alerted, after receiving a call from the Baker Act Coordinator, of concerns in which a patient presented to the Emergency Department (ED) and did not get seen. The Director of the ED stated she did not know the patient's name, but she did some investigation and determined the patient never presented to the Emergency Department. She stated she thinks that the MRT (Mobile Response Team) called the Sheriff's department and the patient was transported to Fort Walton Beach Medical Center. She did not document or complete an incident report; but had left a message for the Risk Manager and had planned to speak with her today about it.

On 10/26/2020 at approximately 12:45 PM a telephone interview was conducted with Patient #20's mother. Patient #20's mother described the events that led up to the visit to the emergency room (ED) on 10/12/2020. The mother stated that after seeking the advice from her daughter's psychiatrist she was advised to call 911, to have her daughter transported to the hospital for a medical evaluation and Baker Act. The mother described that Patient #20 rode in the police car and she followed in her own car. The mother stated they went to the ED and she was handed a form in which she began to complete, as she explained to the girl at the front desk that her daughter needed to be seen and Baker Acted because she had attempted to hang herself. The mother said that the girl in the ER told her "we don't handle Baker Acts," and that if they wanted "her admitted it might be 3 days before someone got to them." She did not complete the registration form. She said, she was upset that it was taking so long. She didn't know what else to do, so she indicated they left the emergency room .

On 10/26/2020 at approximately 1:15 PM, an interview was conducted with Staff Member D, an Emergency Medical Technician (EMT), who works the registration desk in the ED. Staff Member D recalled the mother and Patient #20 coming into the ED waiting room, brought by Staff Member F. Staff Member D stated that the mother came to the desk demanding her daughter be seen and that she needed to be admitted for Baker Act. Staff Member D stated she told the mother that they 'don't admit Baker Acts' and we 'could not see her as quickly' as she was asking (snapping her fingers), she stated to the mother that' it might be 3-5 days before she is seen (by psych.)' Staff Member D did not recall any unusual observations of Patient #20 and did not recall if the mother had started any paperwork. Staff Member D stated that when a patient comes into the ED, she timestamp's the "EMTALA (Emergency Medical Treatment and Labor Act) Sign-in Sheet," and hands the form to the patient or patient representative to complete. Staff Member D did not retain any documentation and stated the form would have been shredded. Staff Member D stated she informed the Charge Nurse.


A review of the hospital's Medical Staff Bylaws, dated April 2018, under Medical Staff Rules and Regulations, Article 3 - EMERGENCY SERVICES, page 5 indicates "3. Screening of Individuals Who Present to Hospital - Any patient that comes to Twin Cities Hospital requesting emergency services is entitled to, and will receive a medical screening examination performed by individuals qualified to perform such an examination to determine whether an emergency medical condition exists. In general, when an individual comes by him or herself or with another person and is not technically in the Emergency Department, but on Twin Cities hospital property, or owned or operated (the) Hospital premises, and requests emergency care, he or she must receive a medical screening examination within the capabilities of that facility or, if necessary, execute an appropriate transfer according to the guidelines of EMTALA and Twin Cities Hospital policies."

Under the heading of "Logistics," - "a. The facility must receipt, arrive, or pre-register the individual (this process will generate a medical record number.) If an individual presents for an MSE but his or her name is unknown, register utilizing Policy SSD.PP.PTAC.217, Naming Convention for Unidentified Patients. b. Open a medical record; offer the individual further medical examination and treatment as may be required to identify and stabilize an EMC. c. Log the individual into the Central Log. d. Discuss with the individual the risks and benefits involved in leaving prior to the medical screening and document the same. e. Take all reasonable steps to secure the individual's written informed consent to refuse or withdraw from such examination and treatment by having the individual sign the Waiver of Right to Medical Screening Examination form, if possible. If the individual refuses to sign the Refusal of Treatment Form, the hospital representative who asked the individual to sign the form must document the refusal on the form and the date and time such refusal occurred.

A review of the facility's policy and procedure entitled "Florida EMTALA - Medical Screening Examination and Stabilization Policy, dated April 2018, indicated "An EMTALA obligation is triggered when: 1. an individual or a representative acting on the individual's behalf, including EMS or a transferring hospital, requests emergency services and ; or care. .......Such obligation is further extended to those individuals presenting elsewhere on hospital property requesting examination or treatment for an emergency medical condition ("EMC").

The procedure for "When an MSE (Medical Screening Exam) is Required," indicates "a. 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. .......b. The individual arrives on the hospital property other than a DED and makes a request or another makes a request on the individual's behalf for examination or treatment for an EMC.