HospitalInspections.org

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Based on medical record (MR) review, observation, document review and interview, in one (1) of twelve (12) MRs, the Emergency Department (ED) did not ensure that MR entries were completed and/or properly filed to document the patient's: (1) Pre-hospital care and treatment; (2) Transfer records from a Skilled Nursing Facility (SNF); and (3) ED disposition (Patient #1).

Findings for (1) included:

Patient #1's MR identified that on 11/26/19 at 8:00PM, Patient #1 arrived by ambulance from a SNF for evaluation of abdominal pain. There was no pre-hospital care documentation found in the electronic medical record (EMR).

The facility furnished an Ambulance Report addendum dated 11/26/19 with an inconsistent timeline of events: The vital sign assessment performed by Emergency Medical Service (EMS) personnel was documented after the ambulance had left the ED drop off area. The original, full Ambulance Report was not furnished despite multiple requests by SA surveyors.

Per interview of Staff H and Staff I (Patient Access Representatives) on 1/30/20 at 12:15PM, both Staff H and Staff I stated that all ambulance care reports are scanned into the EMR. This finding was confirmed by Staff B (ED Medical Director).

Findings for (2) included:

Review of Patient #1's MR identified that no transfer records from the SNF were included in the EMR. The department could not locate or furnish Patient #1's Protected Health Information (PHI) from the SNF despite multiple requests by SA surveyors.

Observation of video surveillance of the ED Ambulance Triage Area for 11/26/19 at 8:06PM identified a physical hand-off of documents from the EMS personnel to Staff D (ED Triage RN/Registered Nurse) upon Patient #1's arrival. Staff D received the documents from EMS, stapled them together, then placed them on a desk in triage area.

Per interview of Staff D on 1/31/20 at 10:10AM, Staff D confirmed the documents received were sent from the SNF via ambulance with Patient #1 and stated, "I don't recall what happened to that paperwork from the Nursing Home."

Per interview of Staff C (PA/Physician's Assistant) on 1/30/20 at 3:15PM, Staff C stated that the information from the SNF that accompanies the patient is a crucial part of the patient examination and evaluation, since it provides information that a nursing home patient cannot always provide if they are a poor historian, have altered mental status, Dementia or Alzheimer's.

This finding was confirmed by Staff B at the time of interview.
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Findings for (3) included:

Review of Patient #1's MR identified this patient was quick-triaged [an initial triage and registration process performed simultaneously to quickly determine a level of severity for treatment and care] in the ED on 11/26/19 at 8:06PM. No patient disposition was documented in the EMR.

Observation of video surveillance of the ED Waiting Area for 11/26/19 at 8:21PM identified Patient #1 exited the main entrance, 15 minutes afer arrival, and did not re-enter the facility.

A facility Incident Report dated 11/27/19 at 1:40PM, 17 hours and 19 minutes after Patient #1 exited the facility, stated that Patient #1 had left the ED without being evaluated (LWOBE) the day prior and that the local law enforcement was conducting a missing person search that included an aerial search by police helicopters.

Per interview of Staff J (Director of Quality Management) on 1/31/2020 at 3:00PM, Staff J confirmed Patient #1 left the ED and a disposition was not documented.

Based on medical record (MR) review, observation, document review and interview, in one (1) of twelve (12) MRs reviewed, the Emergency Department (ED) did not consistently implement its policies and procedures to ensure that: (1) A patient arriving via ambulance was placed into a clinical area after triage; (2) A patient sent to the waiting room after Triage received a clinical reassessment within one hour; (3) A patient who left without being evaluated (LWOBE) by a provider was tracked and trended in the ED quality metrics for corrective action and quality improvement (Patient #1).

These failures may place all patients at increased risk of harm or adverse events.

Findings for (1) included:

Review of the ED policy and procedure (P&P) titled "Triage - Emergency Severity Index (ESI)", last revised 11/12/15, stated "Patients arriving by ambulance will be triaged in order of severity of complaint and assigned to an appropriate clinical treatment area of care."

Review of Patient #1's MR identified that this 71-year-old man arrived via ambulance from a Skilled Nursing Facility (SNF) on 11/26/19 at 8:00PM, accompanied by Emergency Medical Services (EMS) personnel.

An Ambulance Report addendum dated 11/26/19 at 8:00PM identified that Patient #1 had been picked up from his residential SNF, in severe distress and complaining of abdominal pain radiating to his back. His pain level was recorded as a 10 of 10 on a pain scale.

Review of Patient #1's MR identified that at 8:06PM, a triage assessment was performed. Vital signs identified the following: Blood Pressure 157/84, Heart Rate 61, Respiratory rate 16, Temperature 98.7 and Pain Level 5 of 10. Patient #1 was assigned an Emergency Severity Index (ESI) Level 3.

Observation of the surveillance video of the ED Waiting Area viewed for the timeframe between 11/26/19 7:56PM to 11/26/19 8:24PM identified that Patient #1 was wheeled into the ED on an ambulance stretcher by EMS personnel at 7:57PM . Patient #1 was then transferred from the stretcher to a wheelchair by the EMS. A hospital staff member then transported Patient #1 to the main ED Waiting Area, not a clinical treatment area as per facility policy, at 8:14PM.

These findings were confirmed by Staff F (Director Patient Care Services ED) on 1/31/20 at 10:10AM.

Findings for (2) included:

The facility P&P titled, "Triage - Emergency Severity Index (ESI)," last reviewed 11/12/15, stated the following: "Patients in the waiting room will be reassessed at a minimum of every 1 hour. The Triage Nurse is responsible to ensure reassessment of waiting room patients..."

Observation of video surveillance of the ED Waiting Area for 11/26/19 at 8:21PM identified Patient #1 exited the main entrance, 15 minutes afer arrival, and did not re-enter the facility.

Review of Patient #1's MR identified this patient was triaged at 8:06PM. The Nursing Triage Note dated 11/26/19 at 10:38 PM stated, "Tried to locate the patient (by calling his name) at 10:00PM, 10:23PM, and 10:38 PM." There was no documented evidence that Patient #1 received, or an attempt had been made to perform the required hourly (sixty minute) reassessment by the Triage Nurse at 9:06PM, 1 (one) hour after Patient #1's initial triage assessment. No further MR entries were documented for Patient #1 from 11/26/19 at 10:38PM to 11/27/19 at 1:40PM, approximately 13 hours after the Triage Nurse had called Patient #1 for the third time.

These findings were confirmed with Staff A (Associate Executive Director), Staff E (Deputy Chief Nursing Office) and Staff F (Director of Patient Care Services ED) on 1/31/20 at 1:45PM.

Findings for (3) included:

The facility P&P titled, "Leaving Against Medical Advice (Left Without Being Evaluated or Elopement)", last reviewed 2/17 stated the following: "When an adult patient, emancipated minor, or minor with parent or legal guardian leaves a Northwell Health Emergency Department without being evaluated by a licensed provider credentialed to perform a medical screening exam and without notifying staff, the following step shall occur...ALL LWOBE medical records shall be tracked and trended, and reported as part of ongoing Performance Improvement [PI] measures."

There was no documented evidence that Patient #1's MR was tracked and trended and reported as part of the ongoing PI measures, as per facility policy.

During interview of Staff C (PA/Physician Assistant), who had been assigned to evaluate Patient #1, on 1/30/20 at 3:15PM, Staff C stated that she called the patient's name, but that there was no response. Furthermore, Staff C stated that she doesn't document anything unless she sees a patient. "Otherwise, it would generate too much paperwork," and that the nurse would be the one to document if a patient was called and didn't respond.

These findings were confirmed by Staff B (Medical Director ED) on 1/30/20 at 3:15PM.