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.

Based on transfer timeline note review, email bed census report, policy and procedure and staff interviews, the facility failed to accept from a referring facility an appropriate transfer of an individual who required such specialized capabilities and/or such facilities for 1 of 3 (Patient #2) sampled patients that were transferred from the recipient hospital. The hospital had the capability and capacity to accept the transfer of Patient #2 who had an identified emergency medical condition and was on a ventilator in respiratory distress.

Findings include:

Refer to findings in Tag A-2411.
Based on transfer timeline note review, bed census report, policy and procedure and staff interviews, the facility failed to accept from a referring facility an appropriate transfer of an individual who required such specialized capabilities and/or such facilities for 1 of 3 (Patient #2) sampled patients that were transferred from the recipient facility. The hospital had the capability and capacity to accept Patient #2 in transfer who had an identified emergency medical condition and was on a ventilator in respiratory distress.


Review of the Transfer Center's timeline notes revealed Patient #2 was to transfer from the transferring facility on 03/24/2020 for the reason of needing a higher level of care. Patient's #2's diagnosis include screened by nasal swab for COVID-19 [Coronavirus Disease], results pending, shortness of breath, hemoptysis [coughing up of blood or blood-stained mucus from the bronchi, larynx, trachea, or lungs], altered mental status changes, fever of 103.1, now on ventilator and had not received dialysis since Thursday, four days ago. History includes coronary artery disease, and CT [computed tomography] scan of lungs shows diffuse infiltrates [a substance denser than air, such as pus, blood, or protein].

Review of the Transfer Center documentation dated 03/24/2020 at 2:36 PM revealed: "Transfer Information: EMS [Emergency Medical Service] - ED [Emergency Department]. Expected on 3/24/2020. Transfer Reason: Higher Level of Care. Diagnosis: R/O [rule out] COVID-19, shortness of breath, hemoptysis, AMS [Altered Mental Status], fever. Service: Emergency Medicine.

Approval: Physician Acceptance. Status: Complete. Updated 03/24/2020 2:56 PM.

Timeline of canceled request for [Patient #2's name]. Patient expected to arrive at destination this day. Dated: 03/24/2020 at 2:36 PM Call from [Transferring facility's name].
At 2:36 PM, "Request Began. Confirmed [Name of receiving facility] as transfer destination.
At 2:42 PM Request for images sent online.
At 2:50 PM Connected [Transferring Physician's name] to [UF Health Shands Hospital- Receiving Hospital] Pt. [patient] has not received dialysis since Thursday, hx [history] of CAD [coronary artery disease], CT (Computerized Tomography) scan shows diffuse infiltrates, pt. arrive to the ED with shortness of breath, AMS( Altered Mental Status), hemoptysis. COVID-19 swab has been drawn and sent to the lab. Respiratory screening completed. Any influenza like illness: Yes, fever of 103.1. Any Respiratory distress: Yes, now intubated [insertion of a tube into a person for ventilation]. Any out of the country travel: No.
At 2:54 PM Request for images sent. Physician's name] Accepts.
At 2:55 PM [ UF Health Shands Hospital] Accepts.
At 2:56 PM Physician acceptance marked complete for destination [Receiving facility's name].
At 3:03 PM Under direction of administration, checking to see if resources are available to handle pt. due to COVID R/O( Rule out).
At 3:12 PM Admin [Administration] states ok to send for pt.
At 3:20 PM Call to [Transferring facility's name]. Advised her of acceptance. Full copy of the chart has been received and will be scanned. Number provided for nurse report. Ref [referring Hospital] requests flight for transport. Visitation policy addressed.
At 3:28 PM Per ADMIN, transfer to be placed on HOLD until resources are secured.
At 3:29 PM Call to [Transferring facility's name] Advised of new status, she acknowledges HOLD.
At 3:57 PM CN [Charge Nurse] (ER) [emergency room ] called, he states ref called report and he also stated ref RN [Registered Nurse] thinks our ER is setting up transport. Informed him leadership has not approved for pt. to come yet. Informed him I'd contact ref.
At 3:58 PM Call to [Referring facility's name] Called RN (ref), reiterated transfer is on hold until leadership/admin approve for pt. to come. Informed her to not set up transport at this time.
At 5:07 PM Call to [Referring facility's name] Connected with [Name provided] (ref) who states pt. was accepted to [UF Health Shands].Transfer canceled.

During an interview on 03/27/2020 at 8:35 AM, the Chief Nursing Officer stated, they will take patients from other facilities including out of state if the patient needs higher care. Most patients from out of state will come by air but some by ground ambulance. We have a transfer center which handles transfers to and from this facility.

During an interview on 03/27/2020 at 11:30 AM, the Charge Nurse, an RN stated, the charge nurse is told by the transfer center of the impending transfer. I make sure that a physician has taken report and accepted the patient. The transfer center will advise how and where the patient is coming from. Bed placement is also called for the potential admission.

During an interview on 03/27/2020 at 11:45 AM the Medical Director of the ED states, "The physicians can take a call about transferring a patient. It is very rare that we do not accept a patient from any hospital, but with COVID-19 cases we are now reviewing each transfer into this ED individually to be sure there is enough staff, supplies and room availability.

During an interview on 03/27/2020 at 11:55 AM with the Physician who accepted Patient #2 he stated, under no circumstances, except for hospital administration, all patients transferring into this facility are accepted, we never say no. Now with COVID-19 problems, we are looking to see if the ED and hospital can accommodate these patients with staff and supplies, but that is up to hospital administration now. At the time that Patient #2 was to be transferred, the hospital was accepting all transfers even with COVID-19. This request for transfer happened at around 3:00 PM. The Physician who usually is the one who accepts patients was busy, so I took the call and accepted the patient for transfer. I did mention it to the Primary Physician as I was leaving the ED, that I accepted a patient from another state. The transfer center was working on the transfer at the time I clocked out.

Email Bed Census Report

An email titled "UF Health requested info" dated 4/20/2020 at 8:19 a.m. contained the facility's bed status report for 3/24/2020. The documentation provided by the Director of Quality revealed there were six available ICU (Intensive Care Unit) beds on 3/24/2020 when the request for transfer was made for Patient #2. The hospital had the capacity but refused to accept the patient on 3/24/2020 despite having available ICU beds.

Policy and Procedure

Review of policy and procedure titled, "Emergency Patients - Acceptance and Transfer" Policy Number: CP02.014, Category: Patient Care dated 07/18/2019 reads: under III: Patients Who Require Emergency Care: B. Requests for Emergency Transfer to [Facility's name]. Arrangements for emergency transfer and/or admission from another facility's Emergency Department shall be coordinated by the Transfer Center. 1. If the transfer center receives a request for transfer for emergency care from an ED, that request will be directed to the ED Physician in Charge, for determination of the hospital's ability to accept the transfer, in compliance with the requirements of federal and state law. Page 3 of 6 reads: An Appropriate Transfer, as defined below, of a patient who requires specialty services at UF Health Shands shall not be refused if the hospital has the Service Capability and Service Capacity to treat the patient. Definitions: C. Service Capability - The physical space, equipment, supplies, and specialized services that the hospital provides (e.g., surgery, psychiatry, obstetrics, intensive care, pediatrics, trauma care). Also, the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses. This includes coverage available through the hospitals on-call roster. D. Service Capacity - The ability of the hospital to accommodate the individual requesting examination or treatment. The capacity to render care includes the number of persons occupying a specialized unit, the number of staff on-duty, and the amount of equipment on the hospital's premises. Capacity also includes whatever a hospital customarily does to accommodate patients in excess of its occupancy limits.

The facility failed to ensure their policy and procedure was followed for acceptance of transfer for Patient #2 on 3/24/2020, which delayed stabilization and treatment of their emergency medical condition.