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Based on interview, record review and review of facility documentation, the facility failed to ensure the listed physicians who were on call for duty after an initial examination were made available to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition needing transfer in one of twenty sampled patients, (Patient #1).

Findings:

Review of Patient #1's medical record revealed he walked into the facility on 3/05/25 at 5:26 AM, and was triaged at 5:27 AM. The Emergency Department (ED) physician at the time was MD-1. A nurse's note by RN-1 on 3/05/25 at 5:27 AM, read, "Pt (patient) reports cough and shortness of breath X [times] 2 - 3 weeks. States that shortness of breath has worsened over last 3 days, and now coughing up blood, states he feels that he is unable to catch his breath, and that he gets short of breath with minimal activity. Reports ABD (abdominal) pain 6-7 of 10."

A physician note on 3/05/25 at 6:11 AM, by MD-2 documented, "6:11 AM. Radiologist called gave me the CTA chest report. Patient had a large myxoma. He recommended cardiology consultation."

A cardiac myxoma is a noncancerous primary tumor that affects your heart potentially causing blood clots, valve obstruction, shortness of breath, fever and night sweats. They need to be surgically removed to prevent serious complications, (retrieved on 4/24/25 from www.clevelandclinic.org).

A Transfer Center note of 3/05/25 at 7:19 AM, revealed, "Received call from (RN-2) at Baldwin Park FSED (Free Standing Emergency Department). Ref (referral) request consult with LMH (Lake Monroe Hospital) Cardiology. Dx (diagnosis): Cardiac mass, resp (respiratory) distress, R (right) pleural effusion."

The Transfer Center documented the initiation of transfer activities at 7:19 AM on 3/05/25. A related entry in the medical record was made at 7:20 AM, shortly after the 7:16 AM physician note, above, indicating a transfer by RN-2 read, "Call placed to transfer center for Cardiology at Lake Monroe, spoke to (Transfer Center staff member) . . . Awaiting call back with (MD-4)."

MD-4 was on-call for Cardiology at HCA Florida Lake Monroe Hospital.

During an interview of the Patient Safety Director on 4/16/25 at 2:49 PM, she stated that if a call was placed to the Transfer Center, in most cases it would be to effect a transfer and that transfer requests incorporate consultations. She explained there could be situations where only consultation is sought by a specialist at another HCA Florida facility. She said MD-4 was on-call for HCA Florida Lake Monroe Hospital Cardiology at that time. She noted the expectation was that Transfer Center call-outs to requested physicians be answered within 30 minutes.

Review of the Medical Staff Rules and Regulations revealed, "When an on-call physician is contacted by the Emergency Department physician and is requested to respond, it is expected the on-call physician will be immediately available by telephone (or secured a qualified alternate in the event he/she is temporarily unavailable) and be available to respond within a thirty (30) minute period."

During an interview of the Patient Safety Director on 4/16/25 at 2:49 PM, she stated the Transfer Center serviced all HCA hospitals in north Florida and was not managed by Lake Monroe Hospital or Oviedo Medical Center.

In regards to the status of the Transfer Center, during an interview of the Patient Safety Director on 4/17/25 at 10:02 AM, she stated the Transfer Center was owned by HCA and that all Freestanding HCA Emergency Departments used this service. She noted the Transfer Center was an overriding component of HCA, which owned Oviedo Medical Center. She produced a copy of their Facility Transfer Agreement with HCA Florida Healthcare Lake Monroe Hospital and Oviedo Medical Center. In consideration of the relationship between HCA, the Transfer Center and Oviedo Medical Center, any failures on the part of the Transfer Center must be considered as being shared with Oviedo Medical Center and HCA Lake Monroe Hospital.

A Transfer Center note of 3/05/25 at 7:21 AM, indicated, "SW (spoke with) (RN-3), page sent to answering service of (MD-4) (Lake Monroe Cardiology)."

A Transfer Center note dated 3/05/25 at 7:28 AM, revealed, "WOCB (waiting on call back) (MD-4) Lake Monroe Cardiology. Connect to (MD-2) Baldwin FSED." Since the Transfer Center received a request to transfer at 7:19 AM and no other entries indicating a response from MD-4 was made within thirty minutes (7:49 AM) or at any point prior to the patient being picked up by 911 Emergency Medical Services (EMS) at 8:05 AM, the facility was in violation of the above-stated 30 minute requirement in the Medical Staff Rules and Regulations. During an interview with the Patient Safety Director on 4/17/25 at 10:54 AM, she confirmed the 30 minute requirement was not met.

During an interview with the ER (Emergency Room) Director on 4/17/25 at 10:55 AM, she stated they learned in their investigation that the Transfer Center did not connect the call appropriately and was therefore a Transfer Center problem.