HospitalInspections.org

Based on a review of the on-call physician lists for services provided at the hospital for July, August, and September 2018 and interview with administrative staff, it was determined that some lists were incomplete, some were incorrect, and some did not include individual physician names.

Findings include:

1. The "St. Joseph's Health (Paterson) ON-CALL OPHTHALMOLOGY ON CALL LIST FOR 2018" did not include the name of an on-call physician for January 1.

2. The "ST. JOSEPH'S UNIVERSITY MEDICAL CENTER DEPARTMENT OF ORTHOPAEDIC SURGERY ON-CALL HAND SCHEDULE FOR THE MONTH OF JULY 2018" did not include individual physician names for July 20, 21, 22, 24, and 31.

3. The "SOC Telemed (Neuro Call)" on-call list for September 2018 did not include the names of individual on-call physicians.

4. Administrator #4 agreed with the findings.

Based on a review of the emergency department (ED) central log, medical record reviews, and interview with administrative staff, it was determined that the facility failed to maintain a central log on each individual who comes to the emergency department 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.

Findings include:

1. Review of the emergency department central log indicated that Patient #4 presented to the ED on 8/8/18 at 12:04 PM and the disposition was documented as having occurred at 12:06 AM on 8/9/18 - 11 hours and 58 minutes after arrival. The disposition section of the log entry stated: "Left After Triage." The "ED Note Physician" section of the medical contained the entry documented as having been made at 3:39 PM on 8/8/18: "Patient seen and examined. No condition identified that requires immediate treatment. Patient is stable to continue to wait. Charge nurse notified. Patient is also aware and agreeable to the plan." The note contradicts the disposition of "Left After Triage."

2. Administrator #4 agreed with the findings.

37433

A. Based on medical record review, review of facility policies and procedures and staff interview, it was determined that the facility failed to ensure all Emergency Department (ED) patients receive an appropriate medical screening exam (MSE).

Findings include:

Reference #1: Facility policy titled "Medical Screening Exam" states, " ... Medical Screening Exam. The initial and ongoing, evaluation of the presenting patient conducted by a physician/advanced practice nurse/physician assistant/emergency medicine resident ... This evaluation includes a chief complaint history and physical, appropriate diagnostic testing, completion of documentation. ..."

Reference #2: The "Procedure" section of the policy and procedure titled CHEST PAIN PROTOCOL states:
"1. The meeter / greeter or nurse overhead pages the ED PCA (Patient Care Associate) to triage and asks the patient to enter the ED triage area. The meeter / greeter also notifies the nurse of the patient's arrival with a chief complaint of chest pain over the age of 35.
2. Patients arriving by ambulance are expedited by the ED charge nurse.
3. The PCA completes the EKG (electrocardiogram) and presents the EKG to the physician for review and interpretation.
4. The ED physician interprets the EKG, documents the interpretation in the medical record.
5. The ED physician then completes a targeted history and physical exam.
....."

1. Review of Medical Record #3 revealed the following:

a. The patient arrived to the ED on 8/4/18 at 2036 (8:36 PM) with the chief complaint, " I am almost 6 weeks pregnant and I started bleeding today." A pain assessment of three (3) out of ten (10) on the numeric pain scale was documented.

b. The patient was triaged at 2052 (8:52 PM) and assigned an Emergency Severity Index (ESI) level of three (3).

c. The "ED Called to Triage" was entered on 8/5/18 at 0237 (2:37 AM) and stated, "... ED Called to Triage Times Three-No answer ... ." This was six (6) hours and one (1) minute after arriving to the ED.

d. The "ED Disposition Documentation" was entered on 8/5/18 at 0238 (2:38 AM) and stated, "... Patient Left Department: Left without treatment ED Reason for Leaving: Unknown ..."

(i) There was no evidence that Patient #3 received a MSE.

e. The above finding was confirmed by Staff #4.

2. Review of Medical Record #4 revealed the following:

a. The patient was documented to have arrived at the ED and was triaged at 12:04 PM on 8/8/18. The "ED Triage Part 1 - Adult - Text" section stated:
"ED Pivot - Adult
Chief Complaint: having trouble breathing, his/her whole body is cramping. [Sic] woke up with a cold sweat
.....
Tracking Acuity: 2
.....
Pain Assessment Adult
FACES Pain Scale: 8 = Hurts whole lot
....."

b. The "ED Note Physician" section contained the entry documented as having been made at 3:39 PM on 8/8/18: "Patient seen and examined. No condition identified that requires immediate treatment. Patient is stable to continue to wait. Charge nurse notified. Patient is also aware and agreeable to the plan." There were no other physician notes.

c. The "Called to Triage" section stated that the patient was called back to triage from the waiting room at "2228" (10:28 PM) on 8/8/18 - 10 hours and 24 minutes after arrival.

d. The "Discharge" subsection of the EVENT INFORMATION section indicated that the patient disposition from the ED was at "00:06" (12:06 AM) on 8/9/18.

e. Although a physician note stated that the patient was "seen and examined," there was no documentation of the extent of the examination or specific findings. The physician did not give any orders.

3. Review of Medical Record #10 revealed the following:

a. The patient was documented to have arrived at the ED on 8/8/18 at 8:11 PM. Triage was documented to have been performed at 8:18 PM. The Triage section stated:
"ED Pivot - Adult
Chief Complaint: chest pain and palpitations since this morning."
The patient's level of pain was documented as 9 (on a pain scale of 1-10). An ESI Triage Classification of 2 was assigned.

b. An EKG order was entered and completed by nursing staff, per protocol.

c. The patient was documented to have left the ED 6 hours and 14 minutes after arrival.

d. There was no documentation that the patient received a MSE.

4. Review of Medical Record #5 revealed the following:

a. The patient arrived at the ED (Emergency Department) on 8/4/18 at 1845 (6:45 PM) with the chief complaint of head and neck pain. The pain was rated seven (7) out of ten (10) on the numeric pain scale.

b. The patient was triaged at 1909 (7:09 PM) and assigned an ESI level of two (2).

c. It was noted that one "Called to Triage" was entered on 8/5/18 at 0335 (3:35 AM), eight (8) hours and 50 (fifty) minutes after arriving to the ED.

d. The "ED Disposition Documentation" was entered on 8/5/18 at 0335 (3:35 AM) and stated, "... Patient Left Department: Left without treatment ED Reason for Leaving: Unknown ..."

e. There was no evidence that the patient received a MSE.


B. Based on review of medical records, review of facility policy and procedure and staff interviews, it was determined that the facility failed to ensure that all Emergency Department (ED) patients are triaged appropriately upon arrival to the Labor and Delivery (L&D) unit.

Findings include:

Reference: Facility policy titled "Triage of Obstetrical Patients" states, "... Procedure: 1. Upon arrival on the unit, the triage nurse, the charge nurse or her designee will perform a brief interview and assessment of the patient to determine the patient's chief complaint ... ."

1. Review of Medical Record #12 on 9/24/18 revealed the following:

a. The patient arrived to the L&D unit on 8/1/18 at 2017 (8:17 PM) with complaints of contractions and vaginal pressure.

b. There was no evidence that the patient was triaged upon arrival to the L&D unit. The "Progress Notes ...OB Triage" was timed 2330 (11:30 PM).

2. Review of Medical Record #13 revealed the following:

a. The patient arrived to the L&D unit on 8/1/18 at 1837 (6:37 PM) with the complaint, "I have no appetite. I feel tired."

b. The "Admission H&P/Triage ... Chief Complaints" at 2001 (8:01 PM) states, "chills, headache." There was no evidence that the patient was triaged upon arrival to the L&D unit.

3. Upon interview, Staff #18 stated that triage is to be completed upon arrival to the L&D unit.

4. The above findings were confirmed by Staff #4, Staff #18 and Staff #19.




40041

37433

A. Based on review of medical records, review of facility policy and procedure and staff interviews, it was determined that the facility failed to follow its emergency department protocol.

Findings include:

Reference #1: The "Procedure" section of policy and procedure titled CHEST PAIN PROTOCOL states:
"1. The meeter / greeter or nurse overhead pages the ED PCA (Patient Care Associate) to triage and asks the patient to enter the ED triage area. The meeter / greeter also notifies the nurse of the patient's arrival with a chief complaint of chest pain over the age of 35.
2. Patients arriving by ambulance are expedited by the ED charge nurse.
3. The PCA completes the EKG (electrocardiogram) and presents the EKG to the physician for review and interpretation.
4. The ED physician interprets the EKG, documents the interpretation in the medical record.
5. The ED physician then completes a targeted history and physical exam.
....."

Reference #2: The "Procedure" section of policy and procedure titled "Triage Protocol" states: ".....
ADULT MEDICATION PROTOCOL
Tylenol 650mg po (by mouth) once for a pain score > (greater than) 7 (on a scale of 1-10). If patient states a Tylenol allergy, refer to physician for additional medication order.
LABS: Lactic Acid
EKG: for any patient (greater than or equal to) age 35 with complaints of pain from chin to groin
....."

1. Review of Medical Record #6 revealed the following:

a. The patient arrived to the ED on 8/4/18 at 1457 (2:57 PM) with complaints of palpitations and chest pain. A pain assessment of seven (7) out of ten (10) on the numeric pain scale was documented.

b. The patient was triaged at 1501 (3:01 PM) and was assigned a Emergency Severity Index (ESI) level of 2.

c. An electrocardiogram (EKG) was ordered at 1501 (3:01 PM) and completed at 1512 (3:12 PM).

d. The "Emergency Documentation" at 1852 (6:52 PM) stated, "Medical screening performed. [He/she] presents w/ CP [chest pain]. Pt [patient] has history of CAD [coronary artery disease] w/ [with] stents placed. Pt's EKG shows no acute ST-T changes."

e. The EKG for the patient was initialed, however, there was no time noted.

f. Upon interview, Staff #14 stated that the physician practice is to review the EKG findings within five (5) to ten (10) minutes of completion, and then initial and time the EKG document.

g. There was no other supportive documentation addressing that the EKG findings were reviewed prior to 1852 (6:52 PM).

h. The above findings were confirmed by Staff #4 and Staff #14.

2. Review of Medical Record #10 revealed the following:

a. The patient presented to the ED on 8/8/18 at 20:11 (8:11 PM) with a chief complaint of "chest pain and palpitations since this morning." The patient's pain level in triage was documented as a "9" on the numeric pain scale.

b. An ED registered nurse (RN) entered an order for an electrocardiogram as part of the CHEST PAIN PROTOCOL on 8/8/18 at 20:13 (8:13 PM). The printed EKG findings stated:
"Sinus tachycardia
Possible Left atrial enlargement
Cannot rule out Anterior infarct, age undeterminate [sic]
ABNORMAL EKG
....."

c. There was no documentation that the patient received a MSE (medical screening examination). The EKG order was signed by the Chief of Emergency Medicine at 19:41 (7:41 PM) on 8/9/18.

(i) There was no documentation that a PCA presented the EKG to a physician, or attempted to present the EKG to a physician, for review and interpretation.

(ii) There was no documentation that an ED physician interpreted the EKG or documented the interpretation in the medical record.

(iii) There was no documentation that an ED physician completed a targeted history and physical exam. There was no evidence that any history and physical was done.

(iv) The RN did not enter an order for a lactic acid level nor did he/she enter an order, and administer Tylenol, as per protocol. The patient was not documented as having been allergic to Tylenol.

3. Review of the medical record of Patient #11 (same patient as Patient #10; different presenting date) revealed the following:

a. The patient presented to the ED on 8/12/18 at 20:11 (8:11 PM) with a chief complaint, "I have high blood pressure checked it earlier it was 170 earlier."

b. An ED RN entered an order for an electrocardiogram on 8/8/18 at 00:04 (12:04 AM). The printed EKG findings stated:
"Normal sinus rhythm
Normal EKG
....."

c. There was no documentation that the patient received a history and physical examination.

(i) There was no documentation that a PCA presented the EKG to a physician, or attempted to present the EKG to a physician, for review and interpretation.

(ii) There was no documentation that an ED physician interpreted the EKG or documented the interpretation in the medical record.

(iii) There was no documentation that an ED physician completed a targeted history and physical exam. There was no evidence that any history and physical was done.




40041

B. Based on medical record review, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure all patients receive appropriate assessment, management, and treatment of pain.

Findings include:

Reference: Facility policy titled "Pain Assessment and Reassessment" states, "... All reports of pain by the patient/family/caregiver will be assessed and addressed appropriately. Pain will be treated pursuant to physician/LIP orders and/or approved alternative/complimentary therapies ... The RN will assess the patient's level of pain during the initial assessment and, thereafter, a minimum of every 4 hours, or more often pursuant to specialty area guidelines."

1. Review of Medical Record #7 indicated the patient arrived at the ED on 8/4/18 at 1303 (1:03 PM) with a complaint of right lower leg swelling.

a. The patient's pain level was assessed at six (6) out of ten (10) on the facility's numeric pain scale.

b. The medical record lacked evidence of the initiation of a pain treatment plan.

c. The medical record lacked evidence of the use of non-pharmacological interventions to manage the patient's pain.

2. Review of Medical Record #14 indicated the patient arrived at the ED on 9/4/18 at 1740 (5:40 PM) with complaints of pain in the groin.

a. On 9/4/18 at 1743 (5:43 PM), the patient's pain was assessed a six (6) out of ten (10) on the facility's numeric pain scale.

b. The medical record lacked evidence that the patient was reassessed a minimum of every 4 hours after the initial complaint of pain.

c. On 9/4/18 at 2201 (10:01 PM), acetaminophen 975mg stat [immediately] and lidocaine topical, 1 (one) patch now, was ordered.

d. The 'Disposition Documentation' entered on 9/5/18 at 0007 (12:07 AM) states, "... pt seen by MD but eloped before RN intervention."

e. The facility failed to follow its policies regarding assessment, management, and treatment of patients with complaints of pain.

3. The above findings were confirmed by Staff #4.

Based on review of medical records, review of facility policy and procedure and staff interview, it was determined that the facility failed to ensure the transfer form is completed in its entirety for all patients transferred out of the Emergency Department (ED).

Findings include:

Reference: Facility policy titled "New Jersey Universal Transfer Form Guidelines" states, "...Procedure: 1. Prior to transfer to another licensed New Jersey healthcare facility or discharge to home with home health services, the RN, Care Manager and/or other licensed healthcare provider will complete fields #1-29 on the NJ UTF {New Jersey Universal Transfer Form}..."

1. Review of Medical Record #16 on 9/24/18 revealed the following:

a. The patient arrived to the ED on 8/21/18 at 2053 (8:53 PM) with a right groin second degree burn.

b. The patient was transferred to a burn specialist/facility on 8/22/18 at 0307 (3:07 AM). The Universal Transfer form "Mode of Transport" section was not completed in its entirety.

(i) There was no documentation of the accepting facility transport team or the name of the transport service from the sending facility in the medical record or on the transfer form.

2. Upon interview, Staff #4 stated that the receiving facility provides the transportation for the burn facility, however, it was not documented.