Based on interview and record review, the hospital failed to ensure that emergency needs of patients who had cardiac monitoring needs were met in accordance with acceptable standards of practice for 1 of 10 sampled patients (#1). Findings: Cross Reference A1111. A review of the medical record of patient #1 was performed. The patient was triaged in the Emergency Department (ED) on 2/08/18 at 5:02 PM. The ED physician ordered the placement of a cardiac monitor on 2/08/18 at 5:53 PM. There was no evidence in the record that the cardiac monitor was placed on the patient from the time it was ordered to the point at which an unsuccessful cardiopulmonary resuscitation (CPR) code was called at approximately 7:18 PM on 2/08/18. There was no evidence that during the time period between the order for the cardiac monitor and the code, that the ED physician sought to confirm the placement of the cardiac monitor. The physician did not confirm placement of the cardiac monitor, and the patient did not receive any medical supervision regarding her cardiac status prior to the patient receiving CPR.

Based on interview and record review, the facility failed to ensure that emergency services involving cardiac monitoring were supervised by Emergency Department medical staff for 1 of 10 sampled patients (#1). Findings: A review of the medical record of patient #1 was performed. The patient was triaged in the Emergency Department (ED) on 2/8/18 at 5:02 PM. The chief complaint at 5:04 PM on 2/08/18 was "Body cramps since last night/Hypokalemia." The Chief Complaint Comments at this same time read, "Hx (history) of hypokalemia. Sent from work with tremors." The patient's vital signs at 5:02 PM on 2/08/18 were, "Temperature oral: 98.2 DegF (degrees Fahrenheit). Heart Rate 90 bpm (beats per minute). Respiratory Rate Spontaneous: 18 br/min (breaths per minute). Systolic Blood Pressure NBP (Noninvasive Blood Pressure) 89 mmHg (milliliters of mercury) (low). Diastolic Blood Pressure NBP: 52 mmHg (low) O2 (oxygen) saturation: 96%." At 5:52 PM on 2/08/18, physician I wrote, "The patient presents with muscle cramping....with PM Hx (past medical history) of HTN (hypertension) and seizures presents to the ED c/o (complains of) generalized muscle cramping due to low Potassium." The physician's physical exam entries at this time included the following: "General: Alert, anxious, S/P (status post) IV (intravenous) insertion, pt became increasingly agitated and anxious....Pupils are equal, round and reactive to light, vision unchanged....Cardiovascular: Regular rate and rhythm. No murmur. Normal peripheral perfusion. No edema...Lungs are clear to auscultation (bilaterally), respirations are non-labored, breathe sounds are equal. Symmetrical chest wall expansion.... Musculoskeletal: Normal ROM, generalized tenderness to palpation of arms and legs....Neurological: Alert and oriented to person, place, time and situation. No focal neurological deficit observed, CN (cranial nerves) II - XII intact, normal sensory observed, normal speech observed. Psychiatric: Cooperative, appropriate mood & affect....Last admitted : 12/21/17. diagnosed with [DIAGNOSES REDACTED]" Physician orders of 2/08/18 at 5:53 PM read, "Cardiac Monitor ED." The initial nursing assessment was performed on 2/08/18 at 6 PM by registered nurse (RN) A. It read, "Cardiac monitor: limits set and alarms on." This was the last mention in the record regarding cardiac monitoring or telemetry. However, during an interview of Risk Manager E on 3/29/18 at 1:03 PM, she stated that this was a portable vital signs monitor, not a cardiac monitor. Thus, this record entry is not accurate. A nurse's note by RN A at 6:30 PM on 2/08/18 read, "Alert and calm." A nurse's note at 7:08 PM on 2/08/18 by RN A read, "Report to [RN B] ....to assume care at this time." A nurse's note at 7:30 PM on 2/08/18 by RN B read, "Approximately 7:10 PM after receiving report from (RN A) ...." Thus, the two respective nurse entries reflected a patient hand-off time within the time range of 7:08 PM and 7:10 PM on 2/08/18. A nurse's note at 7:30 PM on 2/08/18 by RN B read, "Approximately 7:10 PM after receiving report from [RN A]. ...I went to do my initial assessment on patient in H25. Patient noted covered with blanket, facing wall. I call[ed] patient by name, no response. I touched patient she felt stiff, tried sternal rub, patient remains unresponsive. Pt's [patient's] skin felt cold. Call made to doctors, [physician I] responded, [RN G], ANM (assistant nurse manager) was also aware. Patient transferred to room 58, code blue initiated." A nurse's note by RN G, Assistant Nurse Manager, on 2/08/18 at 7:17 PM read, "Primary RN [RN B] noted assessing pt currently in HW (hallway) 25, pt noted nonverbal/unresponsive/cool to touch/mottled, no pulse noted. CPR (cardiopulmonary resuscitation) initiated, code blue initiated. Pt moved to 58, [physician I] present, respiratory therapist and pharmacist at bedside." A physician entry at 7:18 PM on 2/08/18 read, "Upon RN exam, found pt covered up and unresponsive. Subsequently, code was called. Pt put in room 58. Pt unresponsive; CPR and bagging performed. I was called by overhead to pt room." Physician I's note of 2/08/18 at 7:39 PM read, Pt continued to have no pulse. Pt in asystole; no pulse found. CPR was stopped 7:39 PM." During an interview of physician I on 3/30/18 at approximately 3:47 PM, he stated that he did not have any discussions with nurses regarding new vital signs. He stated that he was not aware that the cardiac monitor had not been placed. He stated that he had not issued any directives to nurses along the lines of an increase in monitoring activity with the patient. He stated that he had not examined the patient at any other time than his documented interaction at 5:52 PM on 2/08/18. The physician did not follow-up with patient #1's cardiac status after ordering the placement of the cardiac monitor for a patient with a chief complaint of body cramps and a history of hypokalemia and anorexia.

Based on review of medical records, policies and procedures, and interview, the hospital did not provide an appropriate medical screening examination, and did not ensure an appropriate transfer for 1 of 20 sampled patients (#1). Findings: 1. Cross Reference A2406. Based on reviews of medical records, Emergency Services Management Report, and interview, the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department (ED), including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 20 sampled patients (#1). 2. Cross Reference A2409. Based on reviews of medical records, policies and procedures, and interview, the hospital did not ensure that an appropriate transfer was provided by failing to provide medical treatment within its capacity that minimized the risks to the individual's health, failing to notify/contact a receiving hospital of the transfer, failing to contact a receiving hospital for available space and qualified personnel for treatment of the individual, and failing to ensure a receiving facility accepted the individual to provide appropriate medical treatment for 1 of 20 sampled patients (#1).

Based on reviews of medical records, Emergency Services Management Report, and interview, the facility failed to ensure that an appropriate medical screening examination was provided that was within the capability of the hospital's emergency department (ED), including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 1 of 20 sampled patients (#1). Findings: Review of the County EMS (emergency management services) Fire Rescue form dated 9/03/2015 documented the following "Summary of Events": "Provider Impression - Primary Impression: Behavioral/Psychiatric Disorder Secondary Impression: Poisoning/Drug ingestion." Summary of events: R-12 responded to call with E-13 for diabetic problems. R-12 arrived on scene to find pt (patient) with E-13 crew and multiple....(Police Department) units sitting down in a chair in his living room c/o (complaint of etoh (alcohol) and possibly took some type of pills. Pt. did admit to drinking alcohol and smoking marijuana today. E-13 crew states pt is not c/o (complaining of) any pain or any problems. Pt was a/o (alert/oriented) x2 gcs (Glasgow Coma Scale - used to describe a level of consciousness) of 13. 'Factors like drug use, alcohol intoxication....can alter a patient's level of consciousness. These factors could lead to an inaccurate score on the GCS. (brainline.org).' Pt. was mumbling a lot and hard to understand. Pt has not taken his psych meds (psychoactive medications) in a few days he stated....(Police Department) on scene advised it was a baker act (Florida law: allows the involuntary institutionalization and examination of an individual) and pt requested transport in an ambulance. Pt was able to walk to R-12 truck and was secured to stretcher for transport to ED. Pt was rude and yelling at this writer initially en route to ER (emergency room ). Pt wanted a drink of water and was advised several times he could not have any and that we had none in the back of the truck for him. Pt asked for normal saline to squirt in his mouth and was given a flush and got mad and angry that it was not water. No IV (intravenous) or vitals taken en route due to pt aggravated. 3/12 Id taken on scene. Radio report given 3 minutes out. Pt was walked into the ER and placed in a chair. Verbal report given to nurse and pt. placed in ER bed." Under "Patient Condition", EMS documented at 1:03 AM: "Patient Admits to Alcohol Use, Patient Admits to Drug use, Alcohol and/or Drug Paraphernalia at Scene." The "Injury Onset" was listed as 9 PM on 9/02/2015 with the "Injury Intent" as "Unintentional". Per EMS documentation, at 12:27 AM and 12:31 AM, Patient #1's heart rate (pulse) was 137 and 127 respectively (normal heart rate 60-100). The Electrocardiogram reading indicated Sinus Tachycardia, an abnormally rapid heart rate. Under "Procedures and Treatments", EMS documented a blood glucose analysis at 12:26 AM. Under "Patient Vitals", B.G. (blood glucose) was 181. The EMS call disposition documented the pt. was taken to Florida Hospital Altamonte, the closest facility. A "Hospital/Receiving agent signature" form read, "I acknowledge that the above pt was transferred to my care." It was signed and had a printed hospital staff name dated 9/03/2015 at 1:21 AM. Review of Patient #1's medical record revealed a [AGE] year old male was admitted on [DATE] at 12:50 AM. The "Emergency Physician Record" reflected that "the patient was seen by the physician at 0126 (1:26 AM) in room 12 and PO (police officer) 116 at bedside. Chief complaint documented 'ETOH' onset PTA (prior to admission) Severity - mild....to ED with PO-116 at bedside for ETOH intoxication. Pt states smoking marijuana. Pt. placed under Baker Act by police per police. Pt. c/o HA (headache) and (arrow down) low blood sugar and wanted to get checked out. Pt. denied SI or HI (suicidal ideations/homicidal ideations). Pt states he has no complaints....pt claims mother called 911 after argument and told....PD that he wanted to hurt himself but denies SI/HI at this time. The past history included diabetes/insulin, hypertension, anxiety disorder, post-traumatic stress disorder, GAD (generalized anxiety disorder) and SAD (seasonal affective disorder), ETOH abuse." The ED physician's wrote, "appears 9/02/2015 M (mildly) intoxicated....tachycardia ....LABS, EKG & XRAYS sections were all blank. The ED physician's "Clinical Impression" was "ETOH abuse/Marijuana abuse." The ED physican wrote, "Pt. stable-Discharge for psych eval-mildly (illegible) and intoxicated no complaints NL (normal) BS (blood sugar) by EMS." The facility failed to ensure that an appropriate medical screening examination was provided for patient #1 with poly-substance intoxication on 9/02/2015 as evidenced by failing to provide ancillary services such as administration of IV fluids, urine drug screen (UDS), blood work for Complete Blood Count (CBC), Metabolic Comprehensive Panel (CMP), bedside glucose monitoring, and blood alcohol level (BAL). An interview was conducted with the Risk Manager (RM) on 9/28/2015 at 3:25 PM. The risk manager stated that at that time, it was related that patient #1 underwent a medical screen for medical clearance and an EKG (electrocardiogram) was completed along with assessments by nurse and physician. She related the patient was not given any intravenous fluids, oral medications, and did not take any blood work to establish the patient's health status prior to discharge to hospital B. The medical record for patient #1 from Hospital B was reviewed. Review of the medical record revealed that patient #1 was admitted to Hospital B on 9/03/2015 at 2:26 AM. Documentation by the ED physician at hospital B revealed in part, "CC (chief complaint ) Psych (psychiatric evaluation)...HPI (history of present illness)...38 y/o c (with) c/o medical clearance/Psych allegedly made statements PTA (prior to arrival) to LEO (Law enforcement officer) that he was depressed/SI/plan to OD (overdose) on his medications & medical c/o ....Laboratory: CBC, CMP, TSH (thyroid stimulating hormone, UA (urine analysis) ETOH, UDS. Physical Examination...PSYCH: Ox3 (oriented times 3)/Normal Mental Health ....allegedly SI PTA but denies now....Labs reviewed: ETOH 160 (elevated) (ETOH -normal: none), UA-1000 Glucose (normal-negative), Accu-check (bedside glucose monitoring) 160 (elevated) (normal 65-100), Urine Drug Screen - (+) (positive for) Amphetamines, (+) Benzo, (+) THC-marijuana, (+) Opiate ... Impression: 1. Acute Suicidal Ideation, by history, 2. Polysubstance Abuse." The medication summary revealed that Patient #1 received Tylenol, normal saline IV bolus of 1000 milliliters, and an appropriate psychiatric evaluation at Hospital B.

Based on reviews of medical records, policies and procedures, and interview, the hospital did not ensure that an appropriate transfer was provided by failing to provide medical treatment within its capacity that minimized the risks to the individual's health, failing to notify/ contact a receiving hospital of the transfer, failing to contact a receiving hospital for available space and qualified personnel for treatment of the individual; and failing to ensure a receiving facility accepted the individual to provide appropriate medical treatment for 1 of 20 sampled patients (#1). Findings: Review of the Emergency Physician Record for Patient #1 read that local law enforcement officers "receiving pt in transfer to ALT (alternate) psych facility." Disposition read, "In care of....PD (police department) to receiving facility. The "Improved" box was checked and the form was signed by the physician on 9/03/2015 at 1:46 AM. The "Emergency Nursing Disposition", dated 9/03/2015 at 2:03 AM and written by a registered nurse from the Emergency Department (ED) reflected that the discharge disposition was "Transfer to other hospital....Transportation: Police, Special needs D/C Accompanied By: Police, Special needs D/C Communication: Nurse to Nurse, Special needs D/C Communication Given To: spoke with charge nurse (Name)." The Triage form, dated 9/03/2015 at 1:21 AM documented the chief complaint as "ETOH". The "Emergency Department Record" documented that "Patient educational materials" with patient #1's name "has been given the following patient education materials: ED...Behavioral Healthcare" telephone number and Postal address as well as "Crisis Stabilization Unit...and Residential Treatment Facility at a different address in Sanford." The Emergency Department discharge instructions read, "(Patient #1) has been given these follow-up instructions: WITH....Behavioral Health within 1-2 days." Interview with the Risk Manager (RM) on 9/28/2015 at 3:25 PM revealed if a patient is leaving the hospital ED and is not going to a system facility, it is a discharge of the patient and therefore given discharge instructions. She related if a patient is going to another facility within the system, it is designated as a transfer. She also related that the patient outcome at the other facility was not known, and therefore to help the patient, discharge instructions were included upon leaving the ED. The RM related the physician documented the patient was to go to a Baker Act receiving facility but no further documentation was available regarding a transfer form. The RM related the documented nurse to nurse communication did not involve an accepting facility nurse, but involved the nurse manager at hospital B's ED. Review of hospital policy #010.060 "Transfer to Non-Florida Hospital Medical Facility at Discharge", effective date 12/09/13, review date 6/24/15, read, "This policy applies to the Emergency Department and inpatient areas when patients are discharged from the Florida Hospital facility and transferred to a non-Florida Hospital medical facility....patient transports within the Florida Hospital System are outside the scope of this policy.....The purpose of this policy is to identify processes ensuring patient safety and compliance with regulatory requirements are met when a patient is discharged from the Florida Hospital to be transferred to a non-Florida Hospital medical facility. This policy addresses three situations of transfer that may occur: 1) Patient is transferred from the Emergency Department or inpatient areas to a non-Florida Hospital medical facility....2) The physician recommends transfer and the patient/legally authorized person (LAP) refuses to transfer 3) The patient/LAP requests transfer and is transferred against medical advice....A need may arise that necessitates sending the patient to another medical facility for continuing care, treatment, and/or service that is not a Florida Hospital facility. Patients with an emergent medical or obstetrical condition sent to a non-Florida Hospital medical facility, must meet requirements for the Emergency Medical Treatment and Labor Act (EMTALA) and the Access to Emergency Services and Care Act. Transfer means sending a patient from a Florida Hospital campus or Emergency Department to a non-Florida Hospital medical facility. The receiving facility admits the patient and provides the same or higher level of care. The accepting physician assumes medical control. Indications for Transfer to a non-Florida Hospital medical facility include: 1. Patient needs service capability not available within the Florida Hospital campus system 2. There is no capacity for service within the Florida Hospital campus system. 3. The patient/legally authorized person requests transfer. 4. Patient needs community mental health services. 5. Service capability has been provided within the Florida Hospital campus system and patient is returning to the sending non-Florida Hospital medical facility. 6. The patient needs long term acute care hospitalization . 7. Florida Hospital cannot meet the request or need for care because of a conflict with its mission. A Non-Florida Hospital medical facility is a hospital facility outside of the Florida Hospital campus system...such as: (six acute care hospitals were listed to include Hospital B). Stabilized means, with respect to an "emergency medical condition," "to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility...." Patient #1 was admitted to this hospital ED with an emergent medical condition and under a Baker Act by law enforcement officers. The patient was examined by the ED physician, and found to be stable for transfer to another hospital for psychiatric needs. The ED record indicated the patient was discharged from this hospital to the ED at hospital B. There was no documentation found that this hospital contacted a receiving facility for available space and qualified personnel for treatment, and did not ensure that a receiving Baker Act facility had accepted or referred patient #1 on 9/03/2015 to a receiving facility to assure an appropriate transfer. There was no documentation found that the hospital ED staff contacted or referred patient #1 to a receiving facility to assure an appropriate transfer. Review of the patient #1's medical record revealed that the patient was appropriately transferred from Hospital B on 9/03/2015 to an in-patient psychiatric Baker Act receiving facility.