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Based on medical record review, document review, and interview, the facility did not implement its policy to ensure that the inappropriate transfer of a patient with unstable Emergency Medical Condition (EMC) was reported to the Center for Medicaid and Medicare Services (CMS) or the State survey agency within 72 hours. This finding was noted in 1(one) of 39 patient records reviewed. (Patient #1).


Findings include:

Review of medical record for Patient #1, at Hospital A, identified a 25-year-old who was brought in by ambulance to the Comprehensive Psychiatric Emergency Program (CPEP) on 3/6/16 at 1:49 PM. Nursing triage documentation at 2:39 PM noted that the patient was verbally aggressive and agitated on arrival and required an immediate assessment. The patient was placed on four-point restraint, and was medicated with anti-psychotic and anti-anxiety medication. The patient was placed on 1:1 observation for combative, loud, agitated, and aggressive behavior.

Review of The Ambulance Call Report dated 3/6/16, noted the following: Unit 50A2 was dispatched to a reported Emotional Disturbed Person (EDP) at Hospital B on 3/6/16 at 1:05 PM. Upon the ambulance arrival at the scene at 1:13 PM, Emergency Department staff at Hospital "B" directed the ambulance technicians to the hospital lobby where they found Patient #1 seated in a wheel chair in Police restraints. New York Police Department officers and hospital staff were at the scene. The patient was transported via ambulance with police escort; they arrived at Hospital A at 1:39 PM. The report noted that while on route to Hospital A, the patient became "very aggressive, violent, and acting out;" she was placed on a stretcher and restrained with seat belts.


At interview with Staff B, CPEP Attending Physician, on 3/24/16 at approximately 1:55 PM, he stated the patient reported to him on 3/7/16 that her belongings (phone) were at Hospital B. Staff B stated that he reviewed the "Prehospital Care Report Summary," and reported to Staff C, either on 3/7/16 or 3/8/16, that the patient was inappropriately transferred from Hospital B.


The facility did not implement its policy titled, "Patient Transfer and Emergency Medical Treatment & Active Labor Act (EMTALA) Compliance," issued 9/15. The policy notes; "If after investigation the hospital finds substantial reason to believe that another hospital violated EMTALA with an inappropriate transfer ... if a valid violation is identified, a report must be made to CMS within 72 hours."


Interview with Staff D on 3/24/16 at approximately 2:00 PM, she acknowledged that the inappropriate transfer was identified on 3/8/16 but was not reported to CMS within 72 hours as specified in their policy. She stated that a report was sent via email to CMS on 3/17/16.

Based on document review and interview, the facility did not implement its policy to ensure that the central log was kept accurate, complete, and contained the disposition for each patient who presents to the Emergency Department for care. This finding was evident in 6 (six) of 39 sampled cases reviewed, (Patient #s 2, 3, 4, 5, 6 and 7).

This failure prevents the tracking of the care provided to each patient who presents to the facility seeking care in the Emergency Department.

Findings are:

The facility did not implement its policy titled "Patient Transfer and Emergency Medical Treatment & Active Labor Act (EMTALA) Compliance," issued 9/15. The policy notes the following: "The Emergency Medical Care Log shall contain specific information including but not limited to: patient name/identification; reason for presentation, and disposition category.


Review of the ED Log covering seven months period from September 2015 to March 2016, revealed that the log did not include the reason for ED visit and the disposition for each patient.

Review of medical record for Patient #2 identified a 47- year-old who was evaluated in the Comprehensive Psychiatric Emergency Program (CPEP) on 1/7/16 at 10:17 PM with complaint of hearing voices. The patient was evaluated and treated in the CPEP and was discharged home on 1/8/16.
The log did not include the reason for the patient's ED visit and the disposition of the patient.


Review of medical record for Patient #3 revealed, the patient with a history of schizophrenia was evaluated in the CPEP on 1/11/16 for aggressive behavior, and was discharged home on 1/12/16 after a period of observation in the Extended Observation Unit (EOU), located in the CPEP.
The ED log did not include the reason for the ED visit and the disposition of the patient.


Review of medical record for Patient #4 identified the patient presented to the ED on 3/12/16 at 7:13 AM for complaints of overdose of unknown powdered substance and seizures. The patient was monitored in the Medical ED and transferred to the CPEP on 3/14/16 for psychiatric evaluation and treatment.
The ED log did not indicate the final disposition of the patient after his evaluation in the CPEP.


Similar findings regarding lack of documentation of the reason for each ED visit, and the final disposition of patients were noted in the ED log for Patient #5, #6 and #7, who were evaluated in the ED on 2/4, 2/24, and 2/25/16 respectively.

At interview with Staff A on 3/23/16 at approximately 2:45 PM, she acknowledged that the reason for presentation and the disposition for each patient was not documented in the ED log.