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Based on record review, interviews and policy and procedure reviews, it was determined the hospital failed to adhere to their provider agreement under CFR §489.20 (l) of the provider's agreement requiring that hospitals comply with 42 CFR §489.24, Special Responsibilities of Medicare Participating Hospitals in Emergency Cases. Specifically, the hospital failed to ensure that 1 of 20 sampled patients found to have an Emergency Medical Condition (EMC), was appropriately transferred to a receiving facility for continued psychiatric/medical treatment. (Patient #3)

Findings include:

Cross refer to A-2409.
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Based on central log, interviews, and policy review, the facility failed to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for one out of 20 sampled patients. (Patient #1)

The findings include:

A review of the central log for the off-campus emergency department, Adventhealth Port Orange ER (AHPO) revealed no documentation related to Patient #1 arriving to the Emergency Department (ED) on February 09, 2023, at approximately 2:00 AM.

On 03/26/24 at 10:45 AM an interview was conducted with the Clinical Regulatory Coordinator. He confirmed that there was no documented encounter for Patient #1 at Adventhealth Port Orange. Patient #1 was not on the ED central log. He stated that Patient #1 should have been on the AHPO ED central log.

A review of Adventhealth's policy and procedure titled "EMTALA" with a last reviewed date of August 2023 was conducted. Page one stated, "All Adventhealth hospital entities, provider based urgent care centers, and free-standing emergency departments must maintain a central log that identifies each individual who comes to the emergency department seeking assistance and includes the circumstances of the treatment or non-treatment provided. Documentation within the central log must also include whether the patient refused treatment, was refused treatment, or whether the patient was transferred, admitted, and treated, stabilized, and transferred, or discharged."

Based on medical record reviews, staff interviews, and policy review, it was determined the hospital failed to ensure that 1 of 20 sampled patients found to have an Emergency Medical Condition (EMC), was appropriately transferred to a receiving facility for continued psychiatric/medical treatment. (Patient #3)

The findings include:

A review of Adventhealth Hospital medical records revealed on January 10, 2023 at approximately 11:32 PM, Patient #3 presented to the Emergency Department (ED) via ambulance with expressions of anxiety. On January 11, 2023, at 12:31 AM, Patient #3 received a Medical Screening Examination (MSE) by an ED physician and was noted to have reports of suicidal ideations and a history of suicide attempts, bipolar disorder, post-traumatic stress disorder (PTSD), depression and alcohol abuse. A psychiatrist conducted a tele-health consultation with Patient #3 and recommended Patient #3 to be continued under Baker Act (Chapter 394, Florida Statutes which provides for voluntary and involuntary assessment/treatment of a person with mental illness), be closely monitored, and when medically cleared, be transferred to a Baker Act receiving facility. On January 11, 2023, at 3:18 AM a case manager initiated referrals to 8 receiving facilities for pending transfer. On January 11, 2023, Patient #3 experienced an escalation of agitation, required numerous medications in attempts to manage the symptoms, and at 5:45 PM was ultimately placed in 4-point soft wrist restraints. At 10:21 PM, Patient #3 broke free from his restraints and struck one of the hospital security officers. On January 12, 2023, at 12:18 AM Volusia County Sheriff's personnel were present to transfer Patient #3 to another hospital. (Facility B)

On January 12, 2023, at 12:33 AM, a registered nurse (RN G) at Facility B documented that an RN (A) from Adventhealth Hospital was calling and attempting to give report on a violent patient that was enroute. RN G from Facility B informed RN A that the protocol for transferring was to be received by the transfer center or by a physician/psychiatrist. RN A continued to provide the report and stated, "I don't care if you take report or not, but you're going to want it and the patient is on his way."

On January 12, 2023, at 12:53 AM Patient #3 presented to the ED at Facility B, received a triage and an MSE at 1:44 AM. The ED physician's examination revealed Patient #3 was transferred by law enforcement to Facility B at the request of Adventhealth Daytona Beach.

On March 27, 2024, at approximately 8:44 AM, an interview was conducted with RN A. She recalled Patient #3 and the events surrounding his transfer to Facility B. She confirmed that Patient #3 was under a Baker Act and patients under Baker Act are considered to have an EMC and would normally be transferred with the consultation and agreement from physician to physician for a transfer.

On March 27, 2024, at approximately 9:04 AM, a video conference interview was conducted with Adventhealth Daytona Beach's Director of Emergency Department. He confirmed that a patient under Baker Act would be considered to have an EMC and would require an accepting physician at a receiving hospital prior to transfer.

A review of Adventhealth's policy and procedure titled Transfer/Transport of Patients to an Acute Care Facility (effective 7/1/22), revealed, "If it is determined that the individual has an emergent medical condition and if the transferring physician's opinion the patient requires transfer to another facility and the benefit of such a transfer outweighs the potential risks to the patient's condition. Transferring Department: Explains the risk of the transfer to the patient or to the patient's representative and has the patient or patient representative sign the transfer consent portion of the Transfer/Transport Consent Form. Makes the necessary transfer arrangements with the receiving facility to ensure the receiving facility has sufficient capacity for treatment and agrees to accept the patient and documents the same on the transfer/transport requirement form. Baker Act/Marchman Act transfers are treated as an emergent medical condition."

A review of Patient #3's records from Adventhealth Daytona Beach and Facility B revealed there was no evidence the transferring hospital requested and received an acceptance from the receiving hospital, evidence of risks and benefits of transfer and that Patient #3 was transferred by qualified personnel.