HospitalInspections.org

Based upon medical record (MR) review, document review and interview, the facility:

A) Failed to report incidents of possible inappropriate transfers (see Tag 2401);
B) Failed to maintain MRs related to individuals transferred to or from the hospital (See Tag 2403);
C) Failed to maintain a complete central log (See Tag 2405);
D) Failed to accept appropriate transfers from a referring hospital (See Tag 2411)

These failures potentially place patients and staff at increased safety risk.

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Based on document review and interview, in 1 (one) of 5 (five) cases reviewed, the facility failed to report incidents of possible inappropriate transfers within 72 hours.

Findings included:

The facility's 24-Hour Nursing Supervisor Report, dated 7/19/19, noted Patient #11 arrived at the facility with an "ulcer on the foot and possible maggots." Patient #11 was evaluated by a physician and returned to the sending hospital.

Per interview of Staff E (Director of Quality) on 8/28/19 at 10:45AM, Staff E stated that the documentation obtained by the sending hospital documented the patient as ambulatory, however when the patient arrived, he was found to be an amputee with an open wound on his stump filled with maggots. Staff E then stated that the hospital wasn't equipped to accept and treat a patient with wound care needs and due to an existing emergency medical condition the patient was sent back to the sending facility.

The hospital could not provide documented evidence that the sending facility was reported as required for an inappropriate transfer.

The facility could not furnish documented evidence that this incident was reported to the Centers for Medicare and Medicaid Services (CMS) or the State Agency (SA) within 72 hours.

Per interview of Staff B (Medical Director) on 8/28/19 at 2:45PM, Staff B acknowledged inappropriate transfers are identified and not reported to CMS or the SA within 72 hours. Staff B stated that some reports are sent to the Office of Mental Health (OMH) as an Article 31 facility, but not to CMS. Staff B stated, "I like to be gracious and don't like to report the sending hospitals."
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Based on document review and interview, in 4 (four) of 4 (four) transfer cases, the facility failed to maintain medical records (MRs) related to individuals transferred to or from the facility.

These failures potentially place patients and staff at increased safety risk.

Findings included:

The facility's Daily Census Logs revealed the following:

On 4/11/19, Patient #12 was accepted for admission and received from the sending hospital. Patient #12 was then documented to have been "sent back to" the sending hospital. Although the patient arrived at this facility and was not admitted, the facility could not furnish the MR from the sending hospital for review.

On 4/18/19, Patient #8 was accepted for admission and received from the sending hospital. Patient #8 was then documented as a "send back" to the sending hospital. Although the patient arrived at this facility and was not admitted, the facility could not furnish the MR from the sending hospital for review.

The same lack of maintaining MRs for patients received from a sending hospital were found for Patient #s 5 and 13 for review period 4/2019 to 5/2019. There was no documented evidence to verify the reasons why the patients were refused admission at the recipient hospital.

Per interview of Staff H (Admitting Manager) on 8/26/19 at 11:15AM, patients that are received from another hospital are kept on the ambulance stretcher in admitting until they are evaluated by a physician, and either "admitted" to an inpatient unit, or "denied" admission and returned to the sending hospital. This was confirmed by Staff E (Director of Quality Assurance). When asked if any physician documentation explaining why patients were "sent back" existed, Staff E replied, "No."

Per interview of Staff E (Director of Quality Assurance) on 8/27/19 at 1:30PM, upon request of the MRs for patients returned to sending hospitals, Staff E replied, "We don't keep them. If they are not admitted, all the paperwork sent from the other hospital is shredded." The facility intake information forms were also shredded along with the patient transfer information.

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Based on interview and document review, in 3 (three) of 3 (three) cases reviewed, the facility failed to: (A) Maintain a central log of each individual who presented to the facility seeking emergency assistance; (B) Maintain all the required elements of a complete central log; and (C) Incorporate patient logs from other areas of the facility where patients may present seeking care.

These failures potentially place patients and staff at increased safety risk.

Findings for (A) included:

Upon request of the (central) log for individuals who presented seeking medical attention, Staff E (Director of Quality Assurance) on 8/26/19 at 10:55 AM stated, "We don't put them on the Census Log [central log], but an incident report could have been filled out by security if they were found on the grounds and were creating any type of disturbance."

The Security Department's Incident Investigation Reports [IIR] revealed the following:

The IIR, dated 12/25/18, documented Patient #14 [unknown name] as "a shirtless male...wearing a straw hat and shorts" who had, "entered [the] lobby demanding to be admitted...[The receptionist] informed subject that he would need to go to a hospital first...Subject became agitated and cursed out reporting officer...[Receptionist] called Amityville PD [Police Department] and subject left lobby and entered red car...subject appeared to be a harm/threat to himself and others...subject left grounds without further incident..."

The facility did not document in a central log that Patient #14 had presented to the facility requesting treatment, was refused, or the patient's disposition.

The IIR, dated 7/3/19, noted that at approximately 11:15PM, the security officer [SO] encountered Patient #15 [unknown name], "...sitting on a bench." Patient #15 stated that "he spoke to someone inside and was told to wait outside." The report then noted the SO had spoken to Staff C (Nursing Supervisor) who informed the SO that Patient #15 "wanted to be admitted and was having suicidal thoughts..." The report then noted that the police were called and took the patient into custody, and that Patient #15 would be taken to another hospital. The patient left in the police car.

The facility did not document in a central log that Patient #15 had presented to the facility requesting treatment, was refused, or the patient's disposition.

The IIR, dated 3/1/19, noted that a woman, Patient #16, was "seen in the parking lot," and was "taken to the Admission Office where the woman stated she was suicidal." The police were called, and security waited with the patient until police arrived. The patient was transported via ambulance to another hospital.

The facility did not document in a central log that Patient #16 had presented, was refused treatment or the patient's disposition.

During interview of Staff E on 8/28/19 at 1:20PM, Staff E acknowledged these findings.
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Findings for (B) included:

Review of the facility's Census Log dated 8/26/19 revealed that the log did not contain all the required elements of a central log, including the person's name, the date/time of presentation and whether the individual refused treatment or was refused treatment.

During interview of Staff E on 8/28/19 at 1:20PM, Staff E acknowledged this finding.

Findings for (C) included:

During interview of Staff E and Staff H (Admitting Manager) on 8/26/19 at 11:45AM, Staff H stated, "Rarely, probably no more than five times a month, people do walk in looking for admission. When that happens, we tell them they need medical clearance first and they need to go to any ED of their choosing."

Staff E confirmed this finding and stated, "Yes, [for] anyone who self-presents, we direct them to the local ED of their choice. If they come with someone and are stable, we will let them drive themselves; but if it isn't considered safe, then we would call SCPD [Suffolk County Police Department] or EMS [Emergency Medical Service] to take them to the nearest hospital."

These [unknown] number of individuals who present seeking medical assistance are not documented onto any type of log, and may, or may not, only be documented on a Security Incident Report. The Incident Report is not incorporated into patient logs from other areas of the hospital where patients may present seeking care.

The facility policy and procedure (P&P) titled, "Patients Presenting to the Admitting Office from the Community: Walk ins," last dated December 2015, instructed staff to "immediately notify the Nursing Supervisor" and "initiate 911." This policy is not consistently applied as police are being called for some patients, but not others (referred out via private vehicle).

During interview of Staff E on 8/28/19 at 1:20PM, Staff E acknowledged these findings.

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Based on medical record (MR) review, document review and interview, in 7 (seven) of 14 (fourteen) MRs, the facility failed to accept appropriate transfers from a referring hospital, despite having specialized services and the capacity to treat the patient.

This failure to accept transfers placed patients at increased safety risk.

Findings included:

Review of Patient #2's MR from the referring hospital identified that this 60-year old male presented to the Mid-Hudson Regional Hospital Emergency Department (ED) via ambulance from an Assisted Living Residence on 4/25/19 at 12:04 PM for aggression and homicidal/suicide ideation. The ED physician assessed the patient and documented that the patient reported feeling suicidal, and carried a history for Schizoaffective Disorder, Bipolar Type 1, Alzheimer ' s/Dementia.

The Consulting Psychiatrist note, dated 4/25/19, stated that the patient had a diagnosis of Schizoaffective Disorder and required inpatient hospitalization for safety. The patient was to be admitted to a psychiatric facility involuntarily. The psychiatrist also noted that the patient needed a Geri Psych bed and that he was being evaluated for transfer to a Psychiatric facility with capacity and capability.

The Transfer Certification noted that the patient was accepted to Brunswick Psychiatric Center and was transferred via ambulance at 12:04 PM on 4/26/18.

Patient #2 was returned to Mid-Hudson Regional on 4/26/19 without completion of the transfer.

The Brunswick Census Log dated 4/26/19 stated that Patient #2 was denied acceptance for "not having a psychiatric diagnosis. "

During interview of Staff E (Director of Quality Assurance) on 8/26/19 at 11:45AM, when asked if Patient #2 was turned back to the sending hospital while en route to this facility, Staff E stated, "We would never turn any patient around who was already en route here. We would accept them no matter what. Patient #2 was denied because he did not have a psychiatric diagnosis. All patients who are received here and treated need a psychiatric diagnosis."

Review of Patient #2's MR from the referring hospital identified this patient had a psychiatric diagnosis of Schizoaffective Disorder.

There was no pre-screening intake documentation or MR available at the recipient hospital facility for review. This documentation had been shredded. During interview of Staff E on 8/26/19 at 11:45AM, Staff E explained, "we shred all the intake information on patients we deny; we don't keep any of that information. We don't need to, it's not our medical record, it's the sending hospitals' information. We conduct paper reviews only."

The Census Logs dated 3/15/19, 4/12/19, 4/23/19, 5/26/19, 5/31/19 and 7/15/19, revealed that Patients # 4, 9, 6, 7, 10 and 17, with Emergency Medical Conditions (EMCs) from sending hospitals, were denied admission.

These patients were recorded on the Census Log as follows:
1) On 3/15/19, Patient #4 was denied acceptance for "social worker sent away."
2) On 4/12/19, Patient #6 was denied acceptance for "too far"
3) On 4/23/19, Patient #7 was denied acceptance for "sent back by MD"
4) On 5/26/19, Patient #9 was denied acceptance for "showed up in four point restraint"
5) On 5/31/19, Patient #10 was denied acceptance for "no psychiatric diagnosis"
6) On 7/15/19, Patient #17 was denied acceptance for "no psychiatric diagnosis"

Further review revealed there were no pre-screening intake documentation or MRs available for surveyors to review the denial reasons.

There was no available policy to explain the process of the Recipient Facility's denial of patients with psychiatric EMCs.

Per interview of Staff E on 8/27/19 at 11:20 AM, Staff E acknowledged these findings.