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Based on video review, interview, emergency room logs, record review, policy and procedure review, the facility failed to ensure all individuals presenting to the hospital's off-site free-standing emergency department for care received an appropriate medical screening examination within the off-site free-standing emergency department's capabilities (including but not limited to the ancillary obstetrical services routinely available to an emergency department) to determine whether an emergency medical condition existed for two (2) of 20 sampled patients, Patients #1 and #2, who presented to the hospital's off-site free-standing emergency department with pregnancy related conditions. On June 24, 2025, Patient #1, presented to the hospital's off-site free-standing emergency department at 10:18 PM with a chief complaint of abdominal pain; gestational age of 16 weeks. On May 19, 2025, Patient #2 presented to the hospital's off-site free-standing emergency department at 5:16 PM with a chief complaint of pelvic pain; gestational age of 20 weeks. The hospital's off-site free-standing emergency department had the capability and capacity to conduct medical screening examinations to determine if an emergency medical condition existed, however, the patients were not provided an examination and/or treatment. The facility failed to secure each patients' informed consent and failed to document the patients leaving without being seen.

Findings:

Cross Refer to A2406: Medical Screening Examination.

Based on video review, interview, emergency room logs, record review, policy and procedure review, the facility failed to ensure all individuals presenting to the hospital's off-site free-standing emergency department for care received an appropriate medical screening examination within the off-site free-standing emergency department's capabilities (including but not limited to the ancillary obstetrical services routinely available to an emergency department) to determine whether an emergency medical condition existed for two (2) of 20 sampled patients, Patients #1 and #2, who presented to the hospital's off-site free-standing emergency department with pregnancy related conditions. The hospital's off-site free-standing emergency department had the capacity and capability to conduct medical screening examinations to determine if an emergency medical condition existed when Patient #1 and Patient #2 presented to the emergency department. Patient #1 and Patient #2 were dismissed without treatment or being seen. The facility failed to secure each patients' informed consent and failed to document the patients leaving without being seen.

Findings include:

1. Review of the "Emergency Department Log OH [Orlando Health] Emergency Room and Medical Pavilion Blue Cedar" dated 6/24/2025 at 10:20 PM documented, "[Patient #1's name] CC [chief complaint] abd pain; 16wks preg [abdominal pain; 16 weeks pregnant]. ED [Emergency Department] Disposition" was blank.

Review of Part 1 of the video footage, no audio, of the ED parking lot dated 6/24/2025, showed Patient #1 walked into the ED on 6/24/2025 at 22:18 09 seconds (10:18 PM)

Review of Part 2 of the video footage, no audio, dated 6/24/2025 at 22:18 45 seconds Patient #1 was observed at Registration window. At 22:22 (10:22 PM) and an individual is observed coming out of a door and speaks with Patient #1 until 22:24 23 seconds (10:24 PM). At 22:24 23 seconds Patient #1 sits down in a chair and is observed texting on a cellular telephone. At 22:28 30 seconds (10:28 PM) Patient #1 gets up and exits the emergency department. The outside video view has Patient #1 getting into a private car.

Review of Patient #1's medical record read, "Discharge date and time of 6/24/2025 at 2234 [10:34 PM]. Discharge information: Disposition: ED dismiss-diverted elsewhere." Review of Patient #1's medical record, no triage was completed, no vital signs were obtained, and no medical screening examination was completed.

During an interview on 6 /30/2025 at 11:19 AM via telephone Patient #1 stated, "I guess I got there [to the emergency department] somewhere about 10 o'clock at night. I went in and they took all my information. I waited maybe five minutes, then the doctor told me I needed to go somewhere else. They said all they could do was an ultrasound, but they couldn't do anything else and told me to go to the main emergency room because they could do more for me there. She told me something like they didn't have the proper stuff, some kind of paper to see if my water broke, but they had it at the main emergency room. I did not get an examination or anything else, they didn't take any vital signs on me. I did not sign any discharge paperwork at all. They did not do anything for me. I was not feeling very good about that at all. I wasn't feeling very good and then I had to get a ride to another hospital. It was a pain to have to go there, and I wasn't feeling very good. I thought I was losing the baby and maybe my water broke, so I thought I needed to be seen right away. I got care at [Name of another local hospital], they did an ultrasound and some other stuff and told me I had to have a stitch put in my cervix to make sure I don't go into labor and lose the baby. I don't know why they are an emergency room [off-site free-standing ED] if they can't give me the care I need. I think they should be able to do that. They did not offer to give me an examination or to transfer me, they never offered me that, they just told me to go to the main hospital."

During an interview on 7/1/2025 at 1:17 PM the Vice Chief of Emergency Medicine stated, "We should not be telling any patients that we don't have the equipment or capability to treat them. We can cover all emergency treatment here at any ED, Main or free standing. If needed, we can transfer to [Name of Hospital]. The free standing ED's are an extension, we should be able to evaluate and send patients to OB [obstetrics] and any higher risk OB patients can be transferred to [Name of Hospital]. Typically, we see all pre 20-week patients, screen and medically treat in the ED, or we will consult OB or send the patient to OB to be seen. If a patient is above 20 weeks, they can be seen in the Main ED and the OB team will come downstairs and see them. If they were in a free-standing ED we could transfer them to the main hospital, or to OB to be evaluated as needed. I would expect complete and accurate documentation of any patient entering the ED. The patients [Patients #1 and #2] should have been seen and a medical screening examination done."

During an interview on /1/2025 at 12:39 PM the Nursing Operations Manager of Emergency Services, stated, "We are a fully equipped ED, have ultrasounds, dopplers, inhouse labs. Each patient encounter should have the appropriate documentation. I would expect that both nurses and the ED doctor would document that a patient left without being seen. Each patient was logged, but they did not get triaged before they left. Each patient should have been brought back, vitals taken and charting completed. The ED Doctor spoke with the patient [Patient #1]. Each patient should have received a medical screening examination. If they didn't want to be seen, we should have followed our policies for left without being seen."

During an interview on 7/1/2025 at 3:05 PM the Medical Doctor A stated, "I believe that I saw her [Patient #1]. She [Patient #1] was worried her water had broken. I explained that we do not have the testing available, we can't do the test to determine that, to do nitrazine [paper to detect ruptured membranes during pregnancy] testing. I did tell her that our main campus was a better alternative, they had the proper equipment to provide that testing. I told her we could do an ultrasound and check fetal heart tones. I don't think we have the specific nitrazine testing strips to have addressed her specific concern. I told her I was happy to see her, but we don't have the capability. I felt that I should give her the option to go where she would get the answer she needed and so she would not have an unnecessary ED visit. In this exact situation I knew I couldn't give her the answer she wanted, and I wanted to do what was best for her. I do now see how this could be an EMTALA [Emergency Medical Treatment and Labor Act] violation. We should have seen her [Patient #1] and evaluated her when she [Patient #1] presented to us. She [Patient #1] did not get a medical screening examination. I could have provided one within our capabilities. If she needed additional testing we could have transferred her, but I thought that I would refer her to the right place. We do have a process for patients who leave without being seen or AMA [against medical advice]. I did not have her sign anything. She [Patient #1] left after I spoke to her, so none of the nurses saw her."

During an interview on 7/2/2025 at 7:08 AM Staff A, Financial Counselor I, ED Registration stated, "She [Patient #1] was not seen, the doctor came out and talked to her and she left after that, no one did vitals. I don't know what she said to her. I just know that the doctor talked to her, and she left."

During an interview on 7/2/2025 at 7:26 AM Staff B, Registered Nurse (RN) stated, " The physician [MD A] walked up to me and told me she [Patient #1] chose to go somewhere else."

2. Review of the "Emergency Department Log OH Emergency Room and Medical Pavilion Blue Cedar" dated 5/19/2025 at 5:21 PM documented, [Patient #2's name] CC pelvic pain-20 weeks pregnant. ED disposition" was blank.

Review of Part 1 of the video footage, no audio, of the ED parking lot dated 5/19/2025, showed Patient #2 walked into the ED on 5/19/2025 at 1716 (5:16 PM).

Review of Part 2 of the video footage dated 5/19/2025 at 17:19 (5:19 PM) Patient #2 was observed at the registration window. On 5/19/2025 at 1733 (5:33 PM) the charge nurse enters from the back into the waiting room and spoke with Patient #2 until 1736 (5:36 PM). Patient #2 is observed getting up and exits the emergency department.

Review of Patient #2 's medical record read, "Discharge date and time 5/19/2025 at 1736 [5:36 PM]. Discharge information: Disposition: ED dismiss-never arrived." Review of Patient #2 medical record, no triage was completed, no vital signs were obtained, and no medical screening examination was completed."

During an interview via telephone on 7/1/2025 at 11:35 AM Patient #2 stated, "I did go to their [South Lake Hospital's] off site emergency room. I did register and then someone came out. I can't remember who and told me that they didn't have what I needed, and I should go to the main Emergency Room. They told me they could do an ultrasound, but they didn't have any OB equipment there and I would need to go to the main ED, so I did. I was not examined; they really didn't do anything except for telling me to go to the main ED. They did not take vital signs. They didn't offer to treat me or take me there. They just told me they couldn't help and where for me to go. I was a little upset; it's a pain to go to another place when you don't feel good and are in pain."

During an interview on 7/1/2025 at 12:39 PM the Nursing Operations Manager Emergency Services, stated, "We are a fully equipped ED, have ultrasounds, dopplers, inhouse labs. We cannot do fetal monitoring, if they need to have continuous fetal monitoring, we can transfer the patient to either South Lake or Winnie Palmer as a physician would determine. We have determined, the nurse acknowledged what she said, that my charge nurse on 5/19/2025 [RN C's name] stated that we did not have the capacity to do fetal monitoring. She stated that she did offer to have her come back and be evaluated. It should be documented. Each patient encounter should have the appropriate documentation. I would expect that both nurses and the ED doctor would document that a patient left without being seen. Each patient was logged but they did not get triaged before they left. Each patient should have been brought back, vitals taken and had charting completed. In one case the charge nurse spoke to the patient; in the other the ED Doctor spoke with the patient. Each patient should have received a screening examination. If they didn't want to be seen, we should have followed our policies for left without being seen."

During an interview via telephone on 7/1/2025 at 6:00 PM Staff C, RN stated, "I really can't remember whether or not I saw this patient. I was told I was seen on video as speaking with her [Patient #2] and then she left. I would not tell a patient we can't provide care to them, but I would explain to them what would happen and let them know if they had problems they would be transferred to either South Lake or Winnie Palmer if they were high risk with complications. I understand that I need to offer patients the opportunity to be seen and evaluated. I can't say that I offered her [Patient #2] that, I can't remember. But historically when anyone has a question about their care I will speak with them and explain that if there is a problem, they will go to the main ED, L&D [labor and delivery] or [Name of Hospital] if there are high risk and have complications. We don't document on them, we would have just entered that they have left AMA. I can't say why I didn't document. I should have documented that conversation."

Review of the policy and procedure titled "Compliance and Ethics Program" read, "4.2 Emergency Treatment and Patient Transfers: we comply with the emergency medical treatment and labor act (EMTALA) in providing emergency medical treatment to patients regardless of ability to pay. Anyone with an emergency medical condition or requesting emergency services is given an appropriate medical screening examination and treatment based on medical necessity. Prompt and effective delivery of emergency care will not be delayed for any reason. ... Each patient who presents at any Orlando Health emergency department must receive an appropriate medical screening examination. Patients with emergency medical conditions, including patients in active labor, will be provided ongoing care until final disposition (admission or transfer). An "emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment bodily functions, or serious dysfunction of any bodily organ or part or with respect to a pregnant woman who is having contractions that there is inadequate time to effect a safe transfer to another hospital before delivery, or that transfer may pose a threat to the health or safety of the woman or the unborn child. Additionally, an emergency may include psychiatric disturbances and symptoms of substance abuse when the patient is considered a threat to themselves or to others. Patients will be transferred to a non Orlando health facility if a patient's medical needs cannot be met at Orlando Health and appropriate care is known to be available at the non Orlando health facility. Prior to transfer the patient must be stable....All organizational emergency departments maintain an encore roster and a log documenting each individual who comes to the emergency department seeking assistance. The log must contain the patients chief complaint, diagnosis and disposition (e.g. Discharge, admission, transfer, left without treatment (LWT), left against medical advice (AMA)."

Review of the policy and procedure titled, "AMA/Elopement/CODE ECHO [a security treat or a security incident]/Left without treatment" read, I. Purpose: this policy outlines the responsibilities related to patient elopement, leaving against medical advice, or leaving without treatment with the organizational goal of the patient's safe return to their assigned medical treatment area using the minimal amount of force and or law enforcement intervention. II. Definitions: When used in this policy, these terms have the following meanings. A. Against medical advice (AMA) any patient or outpatient leaving against medical advice in which the nurse or physician has awareness of their wish to leave. I. Left without treatment (LWT) a patient who registers into the emergency department ED and who decides to leave the ED before the physician's medical screening examination has been completed. III. Policy: It is the policy of Orlando Health that: g. Data regarding the volume of left without treatment events shall be maintained by the respective Emergency Department. IV. Procedure: D. Left without treatment: (Emergency Department and Free standing EDs); 1. If possible educate the individual regarding the importance of the medical exam benefit/risk if not completed. 2. if possible complete one set of vital signs and reassess the patient's condition. 3. have the patient or legal representatives signed the refusal for screening examination section of the informed refusal consent form. 4. document the education, vital signs, assessment, date/time of departure, reason for leaving, and the ability to return as needed or follow up with their primary care physician or clinic.

Review of the policy and procedure titled, "Patients' Rights and Responsibilities" read, "1. Purpose: This policy describes the rights and responsibilities of patients of Orlando Health. IV. Procedure: A. Patients' Rights:1. Access to Care: b. A patient has the right to a medical screening to determine if an emergency medical condition exists and the right to treatment for any emergency medical condition that will deteriorate from a failure to provide treatment."

Review of the policy and procedure titled, "Patient Acuity and Nursing Assessment in the Emergency Department" read, "I. Purpose: This policy provides a. standardized means for assessing patient acuity of all patients presenting for evaluation in Orlando Health Emergency Departments and Free-Standing Emergency Departments. III. Policy: It is the policy of Orlando Health that all: A. Presenting patients will be offered a medical screening exam. B. Emergency Department (ED) patients are assessed promptly after arrival."