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Based on staff interviews and medical record review it was determined that the facility failed to report to CMS or to the New Jersey Department of Health that they had reason to believe an individual was transferred with an unstable emergency medical condition from another hospital, violating the requirements of 489.24 (e).

Findings include:

Reference #1: Administrative Policy, 'Emergency Care & Transfers of Individuals with Emergency Medical Conditions (EMTALA)' Policy: 12. Atlantic Health System [AHA] must report to the Centers for Medicare and Medicaid Services (CMS) or the state survey agency within 72 hours when AHA has reason to believe that an individual was transferred to one of Atlantic Health System's campuses in an unstable emergency condition in violation of the Emergency Medical Treatment and Active Labor Act ("EMTALA")... .

Reference #2: Administrative Policy, "Event Reporting" Procedure: Reporting: 4. The site Risk Manager or designee will review the event and consult with members of PERC [Preventable Events Review Committee] as appropriate to determine if the event, meets the reporting definitions and consult with members of PERC as appropriate. Administrative notification of significant events will be through the chain of command.

1. Review of Medical Record #1, indicated the following:

a. The ambulance run sheet indicates that Patient #1 arrived at the (name of other facility) on 8/24/13. The First Aid Squad EMS Patient Care Report indicates, "Diverted by doctor in ER to go to Newton." Page 2 of the EMS Patient Care Report has an unsigned notation that states "2035, EMS - states that they were told by MD at (name of other facility) not to bring the pt [patient] into ED - EMS was refused to let pt come into ED. EMS was told to come to Newton..."

b. The ambulance indicates that Patient #1 was received by Staff #11, an ED nurse, who signed the run sheet.

c. Newton Memorial Hospital Emergency Room Record indicates that Patient #1 was triaged on 8/24/13 at 2104.

d. Newton Memorial Hospital face sheet indicates the admitting diagnosis for Patient #1 as Alcohol Abuse.

e. In a telephone interview with ED nurse (Staff #11) conducted at 1000 on 9/18/13, he/she confirmed that the EMS personnel told her that Patient #1 was "turned away" from the (name of other facility) SED. Furthermore he/she stated that being aware it was an improper transfer from (name of other facility), he/she notified the supervisor (Staff #14).

f. In an interview with nursing supervisor, Staff #14, on 9/18/13 at 1515, he/she stated that Staff #11 called to notify him/her that Patient #1 was inappropriately transferred to their facility. Staff #14 spoke to the EMS personnel and was told that an ED MD at (name of other facility) SED, diverted Patient #1 and told them to go to Newton Hospital. Furthermore he/she stated that being aware it was an improper transfer from (name of other facility) SED, he/she notified the CNO, (Staff #12).

g. Review of the 24 Hour Administrative Report on 8/24/13 at 2200, indicates, Admin On-Call ___ (Staff #12). "Charge nurse ___ (Staff #11) reported to nursing supervisor that (name of first aide squad) were told by the ER MD in (name of other facility) not to bring the patient [Patient #1] to (name of other facility). EMS said that the ER MD told them to bring the patient [Patient #1] to NMC [Newton Memorial Center]...(sic) The (name of first aide squad) were very upset because (name of other facility) refused to take the patient to receive medical treatment." Follow-up, Staff #2 ED Nurse Manager, Staff #7, Nursing Coordinator. Date 8/24/13.

h. In an interview with Staff #12, CNO, on 9/18/13 at 1350, he/she stated that he/she was unaware that the above incident needed to be reported to CMS or the Department of Health.

i. In an interview with Staff #1, Patient Relations/Risk Management/Legal, on 9/18/13 at 1355, he/she stated that he/she was unaware that the above incident needed to be reported to CMS or the Department of Health.

j. The above findings were confirmed by Staff #1, Staff #2, and Staff #12.

Based on a tour of the ED and staff interview, conducted on September 16, 2013 at approximately 12:50 PM, it was determined that the facility failed to conspicuously post signage specifying the rights of individuals under section 1866 of the Act with respect to examination and treatment of emergency medical condition and women in labor or information indicating whether or not the hospital participates in the Medicaid program.

Findings include:

Reference#1: Administrative Policy, 'Emergency Care & Transfers of Individuals with Emergency Medical Conditions (EMTALA)' Policy: 14. Atlantic Health System will post signs in all emergency departments and in places likely to be noticed by all individuals entering emergency departments, as well as those individuals waiting for examination and treatment, including at the entrances, admitting areas, waiting rooms and treatment areas, specifying the rights of individuals under EMTALA to receive a medical screening examination stabilizing treatment (including for an unborn child). The sign will state that Atlantic Health System participates in the Medicaid program.

1. The following observations of the ED where made on 9/16/13.

a. The entrance to the hospital revealed one sign posted in an area that is not visible from the waiting room that where patients are sitting.

b. The ambulance entrance to the ED revealed no signage posted.

c. The ED triage rooms revealed no signage posted.

d. The ED treatment rooms revealed no signage posted.

2. The above findings were confirmed by Staff #1 and Staff #2.

3. The following observation of Labor and Delivery Unit was made on 9/16/13.

a. The entrance area revealed no signage posted.

b. The Labor and Delivery treatment rooms revealed no signage posted.

4. The above findings were confirmed by Staff #1 and Staff #8.

Based on review of the facility's physician on call lists and staff interview, it was determined that the facility failed to maintain a physician on call list that does not list a physician group practice as opposed to an identified individual physician name.

Findings include:

1. On 9/18/13 review of the physician on call list identified physician group names as on call for the following dates:

a. Pediatrics:

i. 3/25/13 thru 5/5/13

ii. 5/20/13 thru 7/28/13

iii. 8/12/13 thru 9/22/13

b. Spine surgery for the months of April 2013 thru September 2013.

c. Bariatrics for the months of April 2013 thru September 2013.

d. General Surgery:

i. April 1, 3, 5, 7-8, 11, 13, 15, 17, 19, 21-22, 25, 27, and 29 of 2013.

ii. May 1, 3, 5-6, 9, 11, 13, 15, 17, 19-20, 23, 25, 27, 29, and 31 of 2013.

iii. June 1, 3, 5-7, 9-10, 12-15, 17, 19-24, 26-27, and 29-30 of 2013.

iv. July 1, 3, 5-8, 10-11, 13, 15-16, 18-19, 21-22, 24, 26-27, and 29-30 of 2013.

v. August 1-2, 4-5, 7-16, 18-19, 21-24, and 26-30 of 2013.

vi. September 1-2, 4, 6-7, 9-10, 12-16, 21, 23-24, 26-27, and 30 of 2013.

2. Staff #1 confirmed that physician group names were identified for pediatrics, spine, bariatrics, and general surgery instead of physician names.

3. On 9/19/13 at 10:00 AM the ED was toured in the presence of Staff #1 and Staff #2. The on-call list posted by the unit secretary's desk was reviewed and a physician name was not identified for the pediatric and spine surgery services.

A. Based on review of the facility's medical staff bylaws rules and regulations, staff interview, and review of facility policy and procedure, it was determined that the facility failed to define a Qualified Medical Person (QMP) who is able to perform a Medical Screening Exam (MSE) in their hospital bylaws or rules and regulations.

Findings include:

Reference: Facility policy and procedure Subject: 'Emergency Care & Transfers of Individuals with Emergency Medical Conditions (EMTALA)' indicates, "... Policy: All individuals who come to an Atlantic Health System hospital seeking emergency medical treatment must receive an appropriate medical screening examination by a physician or otherwise qualified medical personnel as designated by the Atlantic Health System Board of Trustees. ... "Qualified Medical Personnel" mean those personnel designated by the Atlantic Health Board of Trustees as a QMP, as follows: [1st bullet] The emergency Department ("ED") Physicians who have contracted with Atlantic Health System to provide emergency room service at Atlantic Health System Facilities; [2nd bullet] Qualified residents, physicians assistants, and nurse practitioners while under the supervision of the ED Physician; [3rd bullet] Members of the Trauma Team receiving patients directly for treatment who have not been admitted through the ED; [4th bullet] Members of Labor and Delivery receiving patients directly for treatment who have not been admitted through the ED; [5th bullet] Members of the Pediatric Intensive Care Unit receiving patients directly for treatment who have not been admitted through the ED; [6th bullet] Members of the Neonatal Intensive Care Unit receiving patients directly for treatment who have not been admitted through the ED; and, [7th bullet] Specialty services, when requested by the ED Physician, including cardiologists."

1. On 9/19/13 the Medical Staff Bylaws Rules and Regulations were reviewed in the presence of Staff #1. The Medical Staff Bylaws Rules and Regulations lacked evidence of a definition of a QMP able to perform a MSE of patients.

2. Staff #1 stated that a QMP was defined in the facility's EMTALA policy, as referenced above.

3. The facility's EMTALA policy states in bullet numbers three, four, five, and six, that a MSE can be performed by "members of" various teams/units, but it does not specify who the member is that can perform the MSE, i.e. a doctor, a certified nurse midwife. This was confirmed by Staff #1.






2406 Med Screen

Based on review of the facility's physician on call lists and staff interview, it was determined that the facility failed to maintain a physician on call list that does not list a physician group practice as opposed to an identified individual physician name.

Findings include:

1. On 9/18/13 review of the physician on call list identified physician group names as on call for the following dates:

a. Pediatrics:

i. 3/25/13 thru 5/5/13

ii. 5/20/13 thru 7/28/13

iii. 8/12/13 thru 9/22/13

b. Spine surgery for the months of April 2013 thru September 2013.

c. Bariatrics for the months of April 2013 thru September 2013.

d. General Surgery:

i. April 1, 3, 5, 7-8, 11, 13, 15, 17, 19, 21-22, 25, 27, and 29 of 2013.

ii. May 1, 3, 5-6, 9, 11, 13, 15, 17, 19-20, 23, 25, 27, 29, and 31 of 2013.

iii. June 1, 3, 5-7, 9-10, 12-15, 17, 19-24, 26-27, and 29-30 of 2013.

iv. July 1, 3, 5-8, 10-11, 13, 15-16, 18-19, 21-22, 24, 26-27, and 29-30 of 2013.

v. August 1-2, 4-5, 7-16, 18-19, 21-24, and 26-30 of 2013.

vi. September 1-2, 4, 6-7, 9-10, 12-16, 21, 23-24, 26-27, and 30 of 2013.

2. Staff #1 confirmed that physician group names were identified for pediatrics, spine, bariatrics, and general surgery instead of physician names.

3. On 9/19/13 at 10:00 AM the ED was toured in the presence of Staff #1 and Staff #2. The on-call list posted by the unit secretary's desk was reviewed and a physician name was not identified for the pediatric and spine surgery services.

A. Based on medical record review, staff interview and review of policy and procedure, it was determined that the facility failed to ensure that emergency medical conditions have been resolved for all patients prior to being discharged home.

Findings include:

Reference #1: Administrative Policy, 'Emergency Care & Transfers of Individuals with Emergency Medical Conditions (EMTALA)' Policy: "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be accepted to result in: Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or serious impairment to bodily functions ... . "To stabilize" an emergency medical condition means to provide such medical treatment of the medical condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result... "

1. Review of Medical Record #1 indicates the following:

a. ED Record indicates, Patient #1 was triaged on 8/24/13 at 2104.

b. Newton Memorial Hospital face sheet indicates, Patient #1 was registered on 8/24/13 at 2034, with the admitting diagnosis of Alcohol Abuse.

c. Toxicology report collected 8/24/13 at 2210, indicates, Ethanol 114 [mg/dl] - Legal intoxication >60 mg/dl.

d. In a post survey interview with Staff #2, on 10/2/13 at 0355 he/she stated "Toxicology screens aren't usually repeated because they aren't always indicative of an alcoholic's condition. Alcoholics can function at a higher blood ethanol level than someone who doesn't abuse alcohol." Furthermore, "There is no policy on discharge criteria or care of alcoholic patients. The ED physicians use a 20 or 25 point system to determine if the patient's blood alcohol level has dropped. [For every hour, they determine that their ethanol level drops 20-25 points]. There is no policy on the 20/25 point system."

e. The discharge order was written on 8/24/13 at 2334. Disposition Transport: Ambulatory, Condition: Stable.

f. Nursing Procedure: Discharge Note dated 8/25/13 at 0145, indicates, "Patient discharged to home, ambulating without assistance, patient walking... . Discharge instructions given to patient."

g. Doctors Note dated 8/25/13 at 0154 indicates, "Presenting problem: Altered mental status... brought into ED by BLS because of apparent acute alcohol intoxication. Patient has history of alcohol abuse and today had an alcoholic binge... Labs ordered and reviewed by me... Blood Alcohol Level: 114 mg/dl. Patient observed during Emergency Department evaluation and became progressively more alert... On re-examination patient is ambulating, alert, oriented and fit to be discharged home."

2. There is no evidence in Patient #1's medical record that another Ethanol toxicology screen was done.

3. There is no evidence of documentation in Patient #1's medical record that a 20 or 25 point system was used to determine if the patient's blood alcohol level dropped.

4. There is no evidence that Patient #1's emergency medical condition was resolved prior to the discharge due to no repeat Ethanol levels ordered or drawn.

B. Review of Medical Record #1 indicates the following:

Reference #1: Administrative Policy, 'Emergency Care & Transfers of Individuals with Emergency Medical Conditions (EMTALA)' Policy: "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be accepted to result in: Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or serious impairment to bodily functions ... . "To stabilize" an emergency medical condition means to provide such medical treatment of the medical condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result... "

Reference #2: "Policy and Procedure Manual for Psychiatric Emergency Services/Screening Center" Sequential Process of Requests for Psychiatric Services: 4. Clients to be discharged are provided with appropriate referrals. If the patient is at risk, a check-in plan may be instituted whereby the client calls in to the screening center until linked to the referred source...

1. The patient log given to the surveyors on 9/16/13, indicates that Patient #5 presented to the ED on 8/16/13 at 1503.

a. Review of Patient #5's medical record indicates he was triaged on 8/16/13 at 1503.

i. Triage Note indicates: "recent break up with girlfriend of 7 years, pt [patient] feels suicidal, wants to hang self... ."

ii. Social History: "...Patient drinks everyday, more than 5 drinks per day. Patient currently uses drugs, abuses marijuana."

b. Doctor Notes: 8/16/13 at 1529, Medically Stable for MH [Mental Health] Evaluation.

i. History of Present Illness: "(patient's name) is a 22 year old male who presents to the ED via ambulance for evaluation for worsening depression over the past week. He states that he has had some suicidal ideation but has had no attempts. He presents to the ED as he feels very depressed. He has had prior episodes [depression] in the past... Has history of psychiatric disorder... ."

ii Past Psychiatric History: (+) for depression, (+) prior suicide attempts... .

iii Social History: (+) ETOH, (+) Illicit drug use: Marijuana.

iv Emergency Department Course and Treatment: "Patient's condition remained stable... Patient evaluated by PES clinician and patient is to be discharged home. After the evaluation in the Emergency Department, my clinical impression is Depression."

v. Plan: "Arrangements made for psychiatric outpatient evaluation, patient has no apparent acute or chronic medical condition... is medically cleared pending full evaluation."

c. Nursing Assessment: 8/16/13 at 1540.

i. Psych/Social: Psychiatric/social assessment findings include affect, judgement impaired... Suicidal ideations present, thoughts of killing self with a gun or hanging... PES clinician notified.

ii Suicide Risk Assessment Tool: Suicide Risk Assessment findings: Mental State (Moderate risk): moderate depression, some symptoms of psychosis...

d. Atlantic Behavioral Health Crisis Assessment: 8/16/13 at 1515.

i. Referring Source: Self/Family, "Pt [patient] is a 22 year old male who reports he was brought to the ED by a friend/coworker, at his request and at the suggestion of his mother due to having suicidal thoughts. ...explained that his girlfriend broke up with him... About six weeks ago the pt [patient] reports that (girlfriend's name) and he "split up" ... During the break up argument the pt [patient] briefly held a loaded gun to his head in front of (girlfriend's name), his mother and his mother's boyfriend who removed the gun from the family home. At this time pt [patient] denies that he was going to hurt himself, but wanted (girlfriend's name) to realize how much she was breaking his heart... Pt [patient] reports that for the past week he has been unable to eat or drink water, is having difficulty falling and staying asleep. ...drinks enough etoh to the point of intoxication on payday, 2x a month, but reports that he drank everyday since Friday [8/9/13] and after work on Monday and Tuesday. The pt [patient] presents as anxious and confused [sic]."

ii. Collateral Consulting Comments: (Mother's name) was hoping the pt [patient] agreed to stay on the IPU [Inpatient Psychiatric Unit] for the weekend... She reports she encouraged him to come to NMC [Newton Memorial Hospital] to talk to someone before he ended up holding a gun to his head like he did a few months ago.

iii. Legal History: Caught with THC [Tetrahydrocannabinol] paraphernalia 3 years ago and served 90 days in jail..."

iv. Family History of of Psychiatric Conditions: Depression, Mother reports she is diagnosed with bipolar disorder and her sister is "psycho." Mother reports patient's father was depressed.

v. Signs of Decreased Functioning:
[X] Suicidal Thoughts [X] Change in Appetite [X] Change in Sleep [X] Decrease in Concentration

vi. Risk to Self: Current Suicidal Ideation: Yes

vii. Plan: Yes. "Patient reports he has been having suicidal thoughts for the past week, since his girlfriend left him. Patient reported his thoughts as, 'nothing to live for if I don't have her' and 'might as well put an end to myself.' The pt [patient] reports he has thought about hanging himself but denied picking out a rope or specific place... the pt [patient] reported his thoughts were worst at night when he was alone..."

viii. Impulse Control: Fair, "patient did hold a gun to his head in front of his girlfriend, mother and mother's boyfriend about 6 weeks ago during an argument."

ix. Mood: Sad, Anxious, "more anxious than sad - explained he doesn't want to have the thoughts that he has been having."

x. Clinical Summary Assessment of Problem and Patient Needs: "...reported feeling sad and anxious x 1 week due to his girlfriend breaking up with him... he drank etoh x 5 days, reports he hasn't eaten in a week, has been having trouble falling asleep, racing and intrusive thoughts, suicidal thoughts, and difficulty focusing... Psychiatric admission was briefly discussed in regards to safety, but the pt [patient] was able to come up with a plan for the weekend that did not involve etoh or isolating. APHP [Acute Partial Hospitalization Program] was discussed, but due to the pt's [patient's] work schedule and lack and of insurance and being and an out of state resident this is not an option for him at this time. The pt [patient] is agreeable to outpt [out patient] therapy.

xi. Recommendations; Secured an appointment in Pike County for an intake and referral appointment to obtain medical financial assistance and be linked to an outpt [out patient] therapist and psychiatrist if needed. Pt [Patient] was given a RX [prescription] for Xanax x 3 days to help him sleep.

xii. Psychiatrist Consulted: (psychiatrist's name). 8/16/13 at 1650.

xiii. Disposition; Pt [Patient] will be discharged from ED with an appointment in (name of other county) on 8/20.

e. The discharge order was written on 8/16/13 at 1714.

f. Discharge Instructions: Prepared: 8/16/13 at 1715 by (physician's name).

i. Final Diagnosis: Depression

ii. Follow Up with (name of psychiatrist) in Newton NJ.

iii. Follow up with primary care physician within 2 weeks.

iv. Prescriptions given: Xanax tablet 0.5 mg. Dispense 9 Quantity. Every 8 hours.

g. Nursing Discharge Note: 1719, "Patient discharged to home, ..."

h. Disposition Transport: [On 9/16/13 at 1721] Ambulatory, Condition: Stable. PES Patient? Yes - evaluation completed, patient left the department.

2. There is no evidence that Patient #5's emergency medical condition was resolved prior to the discharge.

3. There is no evidence in Patient #5's medical record that a check-in plan was made, nor was there any evidence that it was discussed as per policy in Reference #2.

Based on staff interviews and review of facility documentation, it was determined that the facility failed to ensure a reasonable registration process for patients seeking treatment, unduly discouraging individuals from remaining for further evaluation.

Findings include:

1. During an interview with Staff #4, he/she stated that during pre triage registration, staff will ask for the patients to fill out a form which includes the patient's name, date of birth and social security number.

a. Review of facility document "Triage Tracking Form" form indicates, "PRINT Patient's Name, Social Security Number ________..."


b. This is a possible deterrent to individuals seeking treatment, without unduly discouraging patients from remaining for further evaluation.

2. Staff #1 and Staff #2 confirmed the above findings.

Based on medical record review and staff interview, it was determined the facility failed to obtain a written consent for a transfer and failed to notify all patients of the risks and benefits of a transfer.

Findings include:

Reference#1: Administrative Policy, 'Emergency Care & Transfers of Individuals with Emergency Medical Conditions (EMTALA)' Policy: 6. (2nd bullet) "Inform the individual, or a person acting on the individual's behalf, of the risks and benefits of examination and treatment ... 10. d. (10th bullet) Informed consent of individual being transferred..."

1. Medical record review for Patient #10 lacked evidence of an informed consent or any documentation explaining the risks and benefits of the transfer.

2. After several requests by the surveyor for an informed consent and documentation explaining the risks and benefits of the transfer for Patient #10, staff #1 stated there wasn't any.