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.

MEDICAL CENTER OF TRINITY 9330 SR 54, STE 401 TRINITY, FL 34655 Aug. 9, 2021
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on medical record review, staff interview, and review of facility policy and procedures it was determined the facility was not in compliance with 42 CFR 489.24. The facility failed a) to document continued ongoing monitoring according to the individual's needs until stabilized for four of twenty patients sampled (see A2407); and b) failed to document a patient who left the facility prior to a medical screening exam for one of twenty patients sampled (see A2407).

Findings included:

Refer to A2407.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on facility record review, policy review and staff interview, it was determined the facility failed to reassess the patient as required to stabilize the medical condition for five (#2, #4, #15, #16, and #17) of twenty sampled patients; and failed to document a patient who left the facility prior to a medical screening exam for one (#7) of twenty sampled patients.

Findings included:

1. A review of facility policy titled Assessment and Reassessment, #ADMIN.II-PC-A.002, 12/2019 states,
*Each patient seeking care or treatment in the Emergency department shall receive an assessment by a qualified individual so the plan of care can be developed to best meet the needs of the patient.
*All patients arriving for treatment in the Emergency Department requesting to be seen by the emergency room [ER] physician are screened and assessed by an ER physician or an Advanced Practice Provider [APP][Licensed Independent Practitioner].
*All patients entering the emergency room are Triaged by a Registered Nurse [RN] and assigned a priority, based upon their presenting symptoms and severity of illness.
-Level 1 Resuscitation-Require immediate lifesaving interventions - Reassessment continuously
-Level 2 Emergent - High-Risk situations, confused, lethargic and disoriented or in severe pain - Reassessment every 60 minutes
-Level 3 Urgent Not in high-risk but need 2 or more resources to diagnose and treat their condition - Reassessment every 60 minutes then every 4 hours after Medical Screening Exam [MSE].
-Level 4 Less Urgent Require one resource to diagnose and treat their condition - Reassessment every 60 minutes - then prior to discharge or every 4 hours after MSE.
-Level 5 Non-Urgent Require no resources to diagnose and treat their condition - Reassessment every 60 minutes and prior to discharge after MSE.

2. A review of Patient #2's medical record documents the patient presented to the emergency department via law enforcement with complaints of suicidal ideation and alcohol use at on 7/10/21 at 15:25. The patient was triaged at 15:44 as emergency severity index (ESI) acuity level 2. The patient was seen by the emergency department provider. The chart demonstrated that the patient would need to be medically cleared in several hours because his alcohol was 351. The patient was placed under Baker Act and seen by the psychiatrist via telemedicine. The patient was determined to no longer be suicidal by the psychiatrist and the Baker Act was rescinded at 18:51 because the patient was intoxicated when it was placed. The psychiatric consult documented clinical sobriety, but the emergency department provider did not. Since alcohol levels were not reassessed, the stability of the patient could not be determined. The ED provider treated the patient, however did not document that the patient was clinically sober. They did document that the patient was awaiting a sober ride home. Patient #2 was discharged home on 7/10/21 at 18:49 for outpatient follow-up and substance abuse treatment. A detailed review of the medical record with the Director of Patient Safety failed to show a documented reassessment every 60 minutes by the RN and continued review failed to document any change in ESI level. The patient's chart does not have appropriate repeat vital signs nor was the patient reevaluated in the provider's notes to determine that the patient was sober and stable for discharge. The provider documents the need for a recheck of the patient's alcohol level which was not done. This caused the delay in completion of the medical screening exam and stabilizing treatment.

3. A review of Patient #4's medical record documents the patient arrived to the facility's emergency room as a walk-in on 07/22/2021 at 17:03. Patient was triaged and received a medical screening exam [MSE]. Patient was triaged at 17:18 as ESI acuity level 2. A detailed review of the medical record with the Director of Patient Safety failed to show a documented reassessment every 60 minutes by the Registered Nurse (RN) and continued review failed to document change in ESI level. Patient was transferred to a Behavioral Health hospital on [DATE] at 06:07.

4. A review of Patient # 15's medical record documents the patient arrived to the facility's emergency room as a walk-in on 03/01/2021 at 06:52. Patient # 15 was triaged and received medical screening exam [MSE]. Patient # 15 was triaged at 07:03 as ESI acuity level 2. Patient reassessed by the RN at 09:41 approximately 2.5 hours after triage. The next reassessed by the RN documented at 11:39 approximately 1.5 hours after last reassessment. Patient discharged on [DATE] at 12:18. A detailed review of the medical record with the Director of Patient Safety failed to show a documented reassessment every 60 minutes by the RN and continued review failed to document a change in ESI level.

5. A review of Patient # 16's medical record documents the patient arrived to the emergency room as a walk-in on 03/12/2021 at 14:13. Patient was triaged and received a medical screening exam [MSE]. Patient was triaged at 14:22 as ESI acuity level 2. The patient was discharged to home at 16:35. A detailed review of the medical record with the Director of Patient Safety failed to show a documented reassessment every 60 minutes by the RN and continued review failed to document a change in ESI level.

6. A review of Patient # 17's medical record documents the patient arrived to the emergency room as walk-in on 03/20/2021 at 11:33. Patient was triaged and received medical screening exam [MSE]. Patient was triaged at 11:37 as ESI acuity level 2. The patient was discharged to home at 13:00. A detailed review of the medical record with the Director of Patient Safety failed to show a documented reassessment every 60 minutes by the RN and continued review failed to document a change in ESI level.

On 08/09/2021 at 1630 an interview with the Director of Patient Safety and Nursing Director of Emergency Services confirmed the above findings stating the RN should document reassessments per policy.

7. A review of facility policy titled EMTALA Definitions and General Guidelines, #ADMIN.LD.011, effective 11/2019 stated, on page 10 of 16, (C) When the Individual Leaves Before the EMTALA Obligation is Met, (1) (c) if the individual leaves the facility prior to triage but the individual is not seen when he/she leaves, document the number and time of attempts to locate the individual for screening.

A review of facility policy titled EMTALA - Florida Medical Screening Examination and Stabilization, #ADMIN.LD.009, effective 10/2019 stated, on page 11 of 15, (d) Documentation of Unannounced Leave, if an individual leaves the facility without notifying facility personnel, this must be documented upon discovery. The documentation must reflect that the individual had been at the facility and the time the individual was discovered to have left the premises. If the individual leaves prior to an MSE (Medical Screening Examination), the information should be documented on the individual's medical record.

8. Review of the medical record for Patient #7 revealed the patient was recepted on 6/14/2021 at 1:16 am. The patient's stated complaint was productive cough times one week even after prescribed medication. The patient's vital signs, height and weight were assessed, no time documented. Review of the record revealed at 1:54 am the patient was removed from the tracker. Review of the record revealed no further documentation of when the patient was discovered to have left the premises, if the patient notified facility personnel of the intent to leave, nor documentation of attempts to locate the patient.

On 08/09/2021 at 4:40 pm an interview with the Director of Patient Safety and Nursing Director of Emergency Services confirmed the above findings.