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Based on the tour of the facility, it was determined the hospital failed to ensure conspicuous display of signs in designated areas that specify the rights of patients to examination and treatment of emergency conditions and for women in labor in accordance with Section 1867. Specifically, the Labor and Delivery (L&D) Triage and Treatment area had no postings of EMTALA signage.

Findings include:

During tour of the Labor & Delivery (L&D) triage and treatment area on 4/21/14 between 11:30 AM and 11:55 AM it was observed that EMTALA signage were not posted at the entrance to the L&D Department, the waiting room and treatment areas.

At interview with Staff #1 on 4/21/14 at 11:35 AM, she stated EMTALA signage are posted in the ED (Emergency Department), but acknowledged the requirements to have signs posted conspicuously in the L&D triage and treatment area where pregnant women and women in labor are evaluated and treated.

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Based on staff interview, review of Labor & Delivery Log and CPEP (Comprehensive Psychiatry Emergency Program) Log, it was determined the facility failed to maintain a complete and accurate log. Specifically, the Labor & Delivery Triage Log did not indicate a disposition for each patient entered into the log and the CPEP log failed to reflect the accurate disposition of each patient. This finding was noted in 5 of 30 sample records from the October - December 2013 logs, and the January - April 2014 logs.

Findings include:

1. The review of the January 2014 L&D log on 4/21/14 revealed Patient #1 was entered into the log on 1/23/14 with no disposition indicated. The patient's chief complaint or reason for the visit was not documented on the log.

The review of patient's record reveals a 24 year-old female, Gravida (# of pregnancies) 1, Para (# of > 20 week births) 0, at 36 weeks 5 days gestation who was evaluated in the L&D triage on 1/21/14 for preeclampsia (a multi-system disorder of pregnancy traditionally characterized by the occurrence of elevated blood pressure and significant amounts of protein in the urine). The hospital summary sheet reviewed on 4/21/14 shows that the patient was admitted on 1/21/14 to Obstetric Services and discharged home on 1/25/14.

2. Medical record for Patient #2, notes that this 29 year-old female, Gravida 2, Para 1, at 40 weeks gestation presented to the L&D triage on 3/1/14 and was triaged at 9:45 PM with complaints of bloody show. The patient was admitted on 3/2/14 at 00:30 AM and discharged from the hospital on 3/5/14. However, the March 2014 L&D log listed the patient's name on 3/1/14, but no additional information was noted on the log regarding her disposition.

3. Record for Patient #3 reviewed on 4/22/14 notes a 29 year-old female at 34 weeks 5 days gestation and her EDC (Estimated Date of Confinement - a term for the estimated delivery date for a pregnant woman) on 3/28/14. On 2/19/14 the patient was evaluated in the L&D triage and admitted to the facility for an elevated bile acid of 241. She was discharged on 2/26/14 in stable condition with a plan for Induction of Labor (IOL) at 37 weeks.

The patient was entered on the L& D triage log on 2/21/14 when she was already an inpatient since 2/19/14. The log did not include the reason for the visit and the disposition of the patient.

4. The record for Patient #4 reviewed on 4/22/14 noted a 22 year-old female at 32 weeks gestation, EDC - 2/21/14. The patient presented on 12/24/13 with complaint of chest pain and vomiting and was diagnosed with gestational hypertension and severe pre-eclampsia (a multi-system disorder of pregnancy traditionally characterized by the occurrence of elevated blood pressure and significant amounts of protein in the urine). She was admitted for antepartum management and magnesium prophylaxis and discharged on 1/6/14 following delivery via caesarean section on 1/2/14.
This patient was entered on the L&D triage log on 12/30/13 even though she had been admitted on 12/24/13. The log entrée for 12/30/13 did not indicate the time of the visit and disposition of the patient.

At interview with Staff #1, on 4/22/14 at 1:15 PM, she stated patients that are evaluated in the L&D triage area are entered into the log daily, so for one patient encounter, the patient's name would be logged in daily until the patient is discharged home. Staff #1 presented L&D log for Patient #1 who was evaluated on 1/20/14 and discharged on 1/25/14. The L&D log shows the patient was entered on the log on 1/20, 1/21, 1/22, 1/23, 1/24 and on 1/25/14. The disposition of the patient was not entered until 1/25/14 when the patient was discharged. Staff #1 acknowledged that L&D daily log serves as a daily patient census for the department.

5. The record for Patient #5 reviewed on 4/22/14 noted that on 11/8/13 this 13 year old female was brought to the ED for psychiatric evaluation for suicidal ideation. The patient expressed on face book that if she continues to be in foster care she will kill herself; she wants to go back to her mother. The patient was evaluated and deemed not to be a danger to self and others. She was discharged to her foster mother with discharge instructions that included an appointment to follow up on 11/15/13 at PM at "NY Foundling". The CPEP log listed the disposition as NY Foundling instead of the correct disposition which is "discharged".

Interview with Staff #2, Associate Director CPEP & Inpatient Psychiatry on 4/22/14 at 3:40 PM, he stated NY Fondling is an Outpatient Treatment Center and the disposition of the patient should have been documented as a discharge.

A2406

Based on interview and the review of medical records it was determined, the facility failed to ensure that each patient presenting to the Emergency Department for evaluation has a timely medical screening examination and treatment. Specifically, patients with acute conditions departed the Emergency Department after waiting long period of time for medical screening examination (MSE). This finding was noted in 2 of 30 patients records reviewed (Patient #6 and #7).

Findings include:

1. Patient #6, a 29 year-old male was brought to the Emergency Department by ambulance on 4/11/14 at 10:59 PM. The patient was triaged at 11:19 PM and as per the history obtained from paramedics, the patient was intoxicated and involved in an altercation. The triage nurse at 11:26 PM notes the patient was pending physician evaluation; he was noted to be calm, sleepy and responding to verbal stimuli; Ethanol - like odor to breath. The patient was assessed as a flight risk and assigned a green gown. Initial vital signs on 4/11/14 at 11:19 PM and a repeat on 4/12/14 at 05:00 PM were stable.

The registered nurse notes on 4/12/14 at 07:09 indicated the patient had been released from the ED. There was no documentation of a medical screening examination for the eight hour the patient was in the ED. The ED log indicated the patient left the ED without being evaluated by a physician.

At interview with Staff #3 on 4/22/14 at 2:30 PM, he stated upon review of the record that the patient was assigned to a physician, but could not determine if the patient was evaluated by a physician as there was no documentation of an assessment.

2. Patient #7 is a 24 year-old male who arrived in the ED by ambulance and triaged on 4/12/14 at 00:08 AM with chief complaint of "eye pain, traumatic" after he was peppered sprayed; additional complaint included alcohol intoxication. The patient's past medical history includes schizoaffective disorder [a mental disorder characterized by disordered thought process (called psychosis) and abnormal emotions (called mood disorder)] and seizures. The triage nurse evaluation revealed redness to patient's face and neck, pain to both eyes, discomfort and injury described as chemical burn. The patient reported that his condition improved after administration of Tetracaine (local anesthetic) eye drops by paramedics. Vital signs obtained on 4/12/14 at 00:18 AM and 06:11 AM were within normal limits.

The nurse noted the patient left without being seen on 4/12/14 at 07:17 AM; this was more than seven hours after initial presentation for treatment of eye injury and pain. The next day on 4/13/14 at 09:35 AM, the physician assigned to the patient noted in the patient's record that "Pt left without being seen, I did not participate in the care of this patient."

At interview with Staff #3 on 4/22/14 at 2:20 PM, he stated the patient was not evaluated by the assigned physician and no medical screening examination was performed.