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Based on record review, it was evident that the medical staff failed to ensure that the care provided to the pediatric patient was effectuated in an organized and efficient manner and that transfer for care not available was delayed.

Findings include:

Review of MR# 1 on 11/15/10 found that the medical care provided to the patient from the medical staff in the ED to the Pediatric unit was deficient. There was sufficient clinical evidence to warrant more timely interventions and where such interventions could not be effectuated, no evidence of escalation of communication of urgency was found. There is evidence other tests were deferred, that the cardiology consultation was by phone and fax until the situation was emergent and that transfer was discussed at approximately 8:45 PM but the call to another hospital for transfer was not made until 10:04 PM.

The patient was treated symptomatically for gastroenteritis on ED visit # 1 which had a duration of about 2 hours and was discharged. No labs were drawn. No studies conducted.

The patient returned to the ED 9 hours after discharge with an increase in gastro-intestinal symptoms and clinically deteriorated over the next 10 hours progressing to cardiac arrest. The patient was admitted from the ED to the pediatric unit.

There was a progressive hypotension and tachypnea. There is no evidence that the hypotension was evaluated nor an attempt to make any clinical correlation with conditions other than dehydration. An EKG was ordered for chest pain at 1000 am but was not completed until approximately 5: 00 PM ( abnormal with massive ST elevation) and there was no evidence that the medical staff reported that this test was not completed for those hours. Therefore, no consideration of a cardiac source was substantiated. On 9/25/10 at 1252 hours, the lab reported cardiac markers troponin 46.400 (H) CK MB FX 155.00, both of which were panic values suggestive of severe cardiac dysfunction. There is no evidence that this was considered in the treatment plan. There is evidence that this value was reported to an unknown staff member referred to by first name, but no corresponding formal notification of the physician was documented in the record until 2059. In the medical record, on the form titled non medication order sheet dated 9/25/10, there was an order timed for either 8:00 PM, or 8 AM (both crossed off) , for troponin and CPK MB stat. Interview with the ordering cardiologist 12/2/10 by phone verified the order as 8:00 PM, ordered only after he was advised of the abnormal EKG done at 5:20 PM (7 hours after the original order for the EKG) .

Where the initial EKG demonstrated a fusion complex with Right Bundle Branch Block and a repeat EKG found ST elevation in the anterolateral leads, the cardiology consult did not respond for 2 1/2 hours. By that time the patient was tachypneic at 51, HR -143 and hypotensive . An EKG was faxed to the cardiologist. A transfer to another Hospital was "planned " for ECHMO. A Pediatric consult note at 8:00 PM discusses transfer to another hospital

There was an echocardiogram (transthoracic ) performed at 1027AM , which demonstrated myocarditis with pulmonary edema but it was rated as a suboptimal study. There was, however, mild to moderate depressed LV systolic function. Report was not signed until 9/27/10 at 1305 hours. There is no evidence that this echocardiogram result was reported to any physician who acted upon it.

There was no official transfer form with an accepting MD found on the medical record except a " consent for transfer " although reference is made that the receiving hospital team arrived during the code 2230. Review of EMS records found that the call to transfer was received at 2204 hours (10:04PM) on 9/25/10. A note by the PCC consultant written 9/26/10 at 12:45 AM stated that " no one was available to discuss this patient. "

Intubation was deferred even though the patient had an oxygen saturation of 81% and persistent tachypnea (rate 54-55). The patient was not intubated until she had ventricular tachycardia and coded.

Based on review of documents and staff interview, the hospital did not completely monitor all aspects of performance, specifically including assessment of the services and operations performed by Medical Records Department.
Findings include:
1. Review of Medical Records Department reports and documents on 11/18/10 determined that the medical records department had not monitored the Correspondence unit for provision of medical record requests.
The department has not addressed the systemic pattern identified for the inability to satisfy external medical records requests within reasonable time frames. The department monitors completion of medical records documentation but there was no evidence during 2010 of review of the trend observed for inability to process complete record requests within time frames required by hospital policy.
Cross-refer to specific findings noted under tag #s A432 and A438.
2. There was insufficient assessment and monitoring by the hospital of the performance of its contracted service (IOD) that is responsible for copying, billing, and mailing of medical records, for which billing and mailing is conducted in the contracted agency's out of state corporate location in Wisconsin.
Interviews with Medical Records departmental staff on 10/18/10 revealed that there was a change in process for provision of medical records approximately 2 years ago. The contracted agency which provides three staff to copy and scan records on site requires that scanned medical record copies be sent to the contracted agency's headquarters in Wisconsin. The Wisconsin office then generates the bills to the requestor, receives payment, performs quality assurance on the records, and then mails the completed medical records to the requestors. Prior to two years ago, these functions were performed on-site at the hospital. Staff was unsure how much time is added for provision of records due to this change in process.
Review of the contract between the facility and IOD on 11/18/10 determined that the hospital is responsible for conducting quality assurance reviews on scanned records that are submitted to the company's central processing corporate center in Green Bay, Wisconsin. Additionally, the hospital is responsible for monthly management reports and analysis.

Review of Medical Records departmental quality assurance documents provided on 11/18/10 included the following documents:

- "Record of Care , treatment, and Services Audit Ongoing Record review at the Point of Care" for June 2010;
-Inpatient and Outpatient Executive Summary tracking reports for case change and code change statistics;
-Coding compliance audit results 4/26/10 and numerical 12/2/08 to 8/19/09 Chart audit counts (which assess completeness and order).

It was determined these reports did not include the assessment of the IOD performance nor the correspondence operations for release of medical records. While individual electronic medical records release tracking files contain an individual QA activity, this is performed on an individual basis and does not reflect trend analysis.

3. There was insufficient documentation of complete investigations of telephone or written complaints received about Medical records Correspondence issues involving delays in release of medical records.
The facility did not comply with its hospital grievance process procedure. Review of the Medical Records Department telephone complaint log for 2010 determined a systematic lack of follow up or was missing documentation of the department's investigations. The medical records telephone information request log was reviewed which revealed approximately 86 inquiries/complaints were received by telephone or in writing between the dates of 1/6/10 and 11/19/10. Of these, approximately 24 contained documentation of follow up whereas the remainder lacked evidence of written actions taken.
For example, on 6/10/10 a call was received for a medical records request that was 200 days old where it was noted the caller was waiting for missing records. No follow up investigation was recorded in the Correspondence follow up section of the log form.
The department did not consistently record follow up of issues raised nor conduct trend analysis. The hospital did not comply with the hospital procedure for grievances, which requires unresolved verbal complaints/phone calls are to be submitted to department heads and to Administration if these remain unresolved at that level. Written complaints or unresolved complaints are forwarded to the Office of the President, where these are tracked and Department heads are notified for follow up.

Based on review of procedures, records and staff interviews, it was determined the facility's medical records department lacked an organized system for the integration of complex activities required for prompt medical record retrieval from multiple locations.

Findings include:

1. The hospital's system to retrieve medical records was not organized in a manner for timely retrieval of medical records within ten days of request as required by hospital procedure. Medical records are stored at the main site and at two off-site locations. Electronic and/or hard copy records are referenced by the year of patient encounter. Records are maintained for the prior year at the main hospital site. ED records from 1980's-1998 are stored on microfilm . ED records between 1999-2009 and other records from 2000-2009 encounters are stored at a warehouse in Melville, Long Island. Records before 2000 are stored at a site in Pennsylvania. It was stated on interview on 11/16/10 that the process of logging requests and researching entire records involves many steps in retrieval from on-site and off-site storage sites. A flow chart diagram involving a 32-step process for successful record releases was provided from an external reference source. While it was stated the hospital's record release activities corresponded to this flow chart diagram, the hospital's existing records release procedures did not reflect this actual practice.


2. The hospital's Medical Records Department did not conduct a causal assessment of delays in management of the high volume of medical records requests received from external sources.

Review of Medical Record Department Correspondence statistics on 11/18/10 revealed the following facts:

-Between 10/1/09 and 10/31/10 (13 months), the Medical records correspondence unit completed 16,092 medical record requests which entailed provision of these copied records to external requestors. These requestors included: patients , authorized representatives, attorneys, or other legally authorized non-billable hospitals/agencies.

These completed copies entailed the copying of approximately 508,921 pages of records. During this same 13 month time period, there were 3693 additional medical record requests received which were not completed by 10/31/10.

Staff interview determined these unprocessed pending requests may be attributed to a myriad of hypothesized reasons, including, but not limited to: non-payment, lack of follow up, storage retrieval delays, coder screening clearance, or other multiple causes. These pending requests, which were not fulfilled within the 10 day required time frame, remained open as "status pending".

-An inquiry into the total number of active cases prior to 10/1/09 determined that the total number of pending medical records requested prior to 10/1/09 included 2,893 outstanding requests which had not been processed (these are defined as requests received between 8/21/06 and 9/30/09,and which remained incomplete). A total of 25,479 completed medical records requests had been fulfilled between the dates of 8/21/06 and 9/30/09.

-Additional data retrieved from the Medical Record Department for correspondence requests determined that since the inception of the electronic record tracking system, between 8/21/06 and 11/18/10, a total of 35,168 record requests were completed, including 1,931,887 pages copied. For this same time period, 6598 requests were received between 8/21/06 and 11/18/10, but were not completed and remain pending.

-Review of additional data submitted by Medical Records correspondence staff revealed that a total of 34,984 phone calls were received by five available clerical staff assigned to process record inquiries and/or follow up during the period between 10/1/09 through 10/31/10. These staff are responsible for data entry of record requests, copying, research of all available patient records for multiple encounters, opening mails, and logging of mail correspondence.

- Staff interview on 11/18/10 determined that the number of phone lines for medical records correspondence inquiries increased from three to seven and that 7 of 10 staff assigned for correspondence duties are presently also required to provide window coverage for walk in requests.

Based on review of procedures , records, and staff interviews it was determined the hospital failed to develop and implement systems for effective coordination of activities for the prompt access, retrieval , and availability of complete patient medical records.

Findings include:

The hospital did not organize an effective system for the prompt organization and retrieval of complete medical records stored both at the main site of the hospital and at off site locations.
Deficiencies were noted in the following areas:
- systematic and repetitive delays were observed in the provision of medical records copies to patients or their authorized representatives within the ten day period in accordance with hospital procedures;
-delays were evident in the retrieval of medical records and integration of activities for coordination of all elements of patients records stored in on-site and off-site locations (in Long Island and Pennsylvania) (see also citations under tag A432);

Details include:
1. The Department of Medical Records- Health Information Management (HIM) failed to implement an effective system to ensure timely retrieval and availability of complete patient medical records following requests made by patients or other authorized persons for these documents.

Review of the procedure titled, "Medical Records- Patient Access to" on 11/15/10 noted the provision of requested information to any qualified person within ten days of a written request. The hospital did not ensure compliance with its procedures which require the timely access and provision of patient records to patients or other authorized persons within ten days of the request.

Ten of ten patient records reviewed in response to complaints determined that complete records were not provided to patients or to other authorized persons within ten days as required by the hospital's procedure for "Patient Access to Medical Records".
Examples:
MR # 19: An electronic medical record tracking form request was created following the authorization submitted with an attorney's request on 12/8/09. This involved multiple ER visits and ambulatory surgery. Attempts were made to locate the birth record for 3/3/2000. On 1/15/10 the employee noted the requestor would take whatever records were scanned but that the record needed required special authorization. Prepayment was requested on 2/1/10 and cancelled on 3/3/10. The entire electronic request was closed on 5/2/10.
A duplicate electronic request was created on 1/27/10 for which it was noted the authorization was not notarized . No follow up was noted until 3/1/10 for invalid HIPAA authorization.
A third electronic request was created on 2/11/10. The records were obtained and reviewed on 2/25/10. On 3/22 /10, it was noted the records for the birth records of 3/3/00 were requested but staff were given records for 2002, 2001, and 1999. On 4/1/10, it was noted the staff still had not received the March 2000 record, which was logged in as pending.
Interview with staff determined the mother's delivery record was missing and was not found at the off site storage facility in Long Island until 11/19/10.

MR#20: The first of two electronic requests was created on 12/7/09. Three emergency records were sent to the attorney on 12/23/09. It was noted that on 1/5/10 the requesting attorney indicated the birth record was not received. Hospital staff explained the authorization was not specific enough. On 1/6/10, a second electronic request was created for the birth record of 3/3/00. The record was received from storage on 1/8/10 but was not reviewed by the coder until 1/31/10. No rationale for this delay was noted. The record was released on 2/1/10. On 9/16/10, the employee noted a duplicate request for the record was received but no authorization was attached. There was no follow up noted.

MR #21: A letter of authorization dated 4/28/10 was submitted by an attorney who requested the complete medical record for this deceased patient. The request was received by the facility on 4/29/10. The first of two electronic request tracking record was created on 5/18/10 in which six records for this patient were identified that required retrieval. The records were requested from storage and reviewed 6/1/10. On 6/7/10 the record noted a special authorization was needed and returned to the attorney on 6/8/10. The record copies were provided on 6/30/10.
A second electronic request was created on 6/14/10 for three of the same records originally requested on the previous tracking form. On 7/7/10, the employee noted that the 7/26/05 chart was not scanned as the record had already been sent. However, the 2009 records were needed. Follow up message was given to pull the records and send to the screener on 7/15/10. On 7/22/10 the secured charts were given to the screener and another record from the clinic was received. From 8/25/10 through 9/28/10 there were notations indicating prepayment and QA activities. Staff reported on interview the bills were sent twice. It was noted during survey this was a secured medical record, meaning it was stored in Risk Management. The remaining copies of secured records were mailed to the attorney by 9/28/10.

MR # 22 The hospital provided an incomplete record to the authorized attorney on 11/16/ 2006. It was determined an operative report was missing from 8/26/06. An electronic request for medical records was created on 8/20/08 in response to the attorney's request for the record but was returned for invalid authorization. A second electronic medical record request was noted 9/12/08 in which it was noted 'OK to process" . The patient record contained evidence of attempts to follow up with the physician on 3/19/09. The provider was no longer on staff at the facility. Despite numerous attempts it was noted on 6/25/09 the physician did not comply with requests to complete the operative report. A letter was submitted to the Department Chairperson dated 9/10/09 requesting help in attempting to intervene with the involved physician and notifying that Administration had the option to notify OPMC. The last correspondence noted was 9/28/09 in which a plan was pending for the physician to complete the report. Follow up interview with staff indicated there was no evidence the operative report was completed.

MR #23: A walk-in request was received at the hospital 7/31/08 from the patient for two inpatient records from 2007. No follow up was noted until 1/14/09 indicating that one of the records for an inpatient admission of 10/19 to 10/22/07 could not be located. A second electronic medical record request was created 11/2/09 which requested the 12/17 to 12/26/07 record. The patient was sent a bill on 11/6/09. The pre-pay was cancelled on 12/6/09. The electronic request form was closed out on 2/4/10 with a "prepay auto close" message. A third electronic request was created on 1/12/10 indicating that the record for the 10/19- 10/22/07 record could not be located and that a complaint was received from the Department of Health. The available admission was given to the patient without charge on 1/12/10. Interview with staff on 11/18/10 determined the warehouse was searched but that the record covering the admission of 10/19/07 -10/22/07 was not found.

MR #24: The original medical records request dated 4/26/10 was sent from the authorized attorney. On 5/11/10, an electronic medical records tracking request was created by the hospital to obtain the records. The records were being located on 5/17/10. On 5/24/10, the requestor called and follow up was provided. These records were not ready for review by the coder until 6/16/10 and review was completed on that date. The medical record was uploaded and QA process completed on 6/24/10. The record was printed and completed for mailing on 6/24/10.

MR #25: The patient requested the medical record on 3/8/10 as a walk in. The electronic request was created 3/8/10. Three ER records and one clinic records were requested from storage on 4/15/10. On 4/15/10, it was noted that one ER record dated 5/22/04 was not on file at the warehouse. Medical records were added on 4/20/10 for which QA was performed by the IOD contractor. Record copies were mailed on 4/20/10.

MR #26: Attorney correspondence dated 5/7/09 was received by the hospital on 5/19/09 which requested the entire patient record. A series of five separate electronic medical record tracking requests were discovered for this patient's records on various dates ranging between 2/27/09 and 2/24/10.
The first electronic request file dated 2/27/09 noted that on 3/26/09, the authorization was not notarized and that on 4/2/09 the HIPAA was invalid.
The second request dated 6/18/09 listed 5 inpatient, 3 ER, and 1 ASU encounters. On 6/24/09, the hospital medical records clerk noted only the 2008 ER charts were given. The hospital received a follow up letter from the attorney on 7/20/09. On 7/31/09 staff noted the requestor would take the 2008 and 2009 records and will call back if older records are needed. On 10/28/09 the coder noted an IM letter for 2003-2006 records. Other records were sent to the contractor IOD for immediate processing. Records were sent on 11/17/09 . However, on 12/10/09 it was noted the attorney still needed the 2003 to 2007 records.
A third electronic file dated 12/14/09 noted that on 12/29/09 the authorization was a photocopy. Another employee was noted to be handling the request on 1/5/10 and the file was canceled.
A fourth electronic file dated 12/30/09 requested different records including 2000-2009 clinic, two ER records from 2004 and 2006, 2 inpatient stays during 2006 and 2009, and one ASU record from 11/6/06. On 1/11/10 the hospital employee noted they did not receive the ASU charts. On 1/20/10 it was noted that ASU's were missing. Several additional communications were noted including communication from Department of Health on 1/25/10. The record was eventually sent on 2/17/10.
A fifth electronic medical record request was created on 2/24/10. The 2/24/10 request noted that authorization must be notarized and the HIPAA authorization was invalid on 3/8/10. The rationale for this notation was not documented, since the record copies had been provided on 2/17/10.

MR # 27: A written medical record request dated 10/1/08 from an authorized attorney was received by the hospital on 10/2/08 for the entire patient record.
Medical records created the first of two electronic tracking files on 10/9/08, in which it was noted the patient had seven charts, including five ED visits, a clinic record, and inpatient record. The first tracking request dated 10/9/08 indicated that on 3/6/09 a missing information letter was sent for the inpatient record 9/19 to 10/13/07. On 3/25/09 it was noted the records were completed and mailed. On 4/6/09 the case was referred to another hospital employee by the coder.
A second electronic tracking request form was created on 1/28/09 for which "facility action" was required. It was noted the patient's signature was a copy. On 2/2/09 it was noted facility action was completed but this action was undefined. On 2/3/09 it was noted the HIPAA was invalid. It was also noted on this date that print was complete but "no records". On 2/9/09 it was noted that the authorization is not an original and contact was made with the law office.
On 3/25/09 the records were completed and mailed except for the 2007 admission. It was stated during interview with facility staff the 2007 record was not located. It was noted during survey the patient's record was secured. A new written medical record request was from the authorized attorney dated 5/4/10. However, there were two stamps on the correspondence that indicated different dates of receipt of the request by the hospital on 5/6/10 and on 6/9/10. No documented follow up was evident.

MR #28: The first of two electronic medical record tracking requests was created on 4/27/09 in response to this patient attorney's request. On 5/14/09 staff noted the need for special authorization. On 5/19/09, a message noted "Print complete-no records" An additional message required "special authorization".
A second record authorization was created on 7/10/09. On 7/13/09, it was noted the records were being located. On 8/11/09, the hospital called the Department of Health to inform the record was located and under review. On 8/12/09 the file noted the medical records were undergoing QA and uploaded. The job was completed on 8/13/09.


2. The hospital has not implemented an effective system to ensure medical records availability and prompt retrieval from storage located at multiple off-site locations. Difficulties were identified in the coordination of activities between the medical records unit at the main hospital site and off campus storage locations.

Five of nine complete medical records (including all encounters) were not provided to the surveyor for more than 48 hours from the initiation of the records request.
The hospital did not ensure timely retrieval of complete patient records in that there was a lack of effective coordination between off site storage facilities and the medical records department. Nine patient records were requested by survey staff on 11/15/10 at 10 AM, of which five complete records with all patient encounters were not readily available and were not provided for more than 48 hours from the time of the initiation of the surveyor's request. While 6 of 9 records were provided the same day of the request, 2 of these were only partial records which did not include all patient encounters.

MR # 19 for the 3/4- 3/7/00 delivery record was requested by survey staff on 11/15/10 and was not located until 11/19/10. This record was originally requested on 1/27/10 by the authorized legal party but was never provided. Staff interview determined this record was missing and discovered in the off site warehouse located in Melville Long Island on 11/19/10. The record copy was provided to the surveyor on 11/22/10.

Complete records including all patient encounters were not provided until 11/17/10 for patient MR #s 23, 26, 27, 28.

It was stated by Medical records managerial staff that clerks must log in and locate all editions of patients' medical records upon receipt of the request. The electronic system used to track requests does not include automatic alerts or flagging of duplicate requests so there may be multiple requests entered unless the employee researches these duplicate electronic requests.

An additional recent sample was reviewed on 11/18/10, which evidenced persistent delays in the retrieval and provision of medical records to patients or authorized requestors. For example, review of the statistics from the September 2010 log of medical records correspondence requests revealed systematic delays in the provision of records to requesting parties. A sample of records requested by patients or attorneys for the month of September 2010 determined that almost half of this sample were not provided within the 10 day time frame. 66 completed medical records were mailed to requestors between 9/1/10 and 9/30/10. Of these, 32 noted delays in provision of records in more than ten days from the initiation of the request.
Examples :
MR#29: Electronic request for medical records created 5/24/10. The storage record was attached 6/2/10 but it was noted one of the records was not scanned in accordance with a limited request. Delay was evident in that review by the coder was not performed until 8/13/10. On 8/9/10, a question was raised if the court document was sufficient. QA of the record was completed on 8/16/10. After some entries about payment, the record was sent on 9/10/10.

MR # 30: Electronic request was created on 6/4/10. Records were being located on 6/14/10 and ready for screening by coders on 6/25/10. They were ready for scanning on 7/12/10. On 7/16/10, the records were checked and available. The request letter was modified and QA completed on 8/6/10. Payment was pending and cancelled request on 8/26/10. On 9/7/10 payment was obtained and records were provided.

MR# 31: Electronic request was created on 6/16/10. The records were being located on 7/15/10. The records were given to the screener for review on 8/27/10. After follow up QA and prepayment notes, the record was mailed on 9/3/10.

MR #32: Electronic request was received on 6/29/10 and created on 7/8/10. The records were being located on 7/14/10 and reviewed on 7/22/10. On 8/23/10, the records were pending screening on coding shelf by coders. On 8/29/10, the records were checked for availability. The records were mailed on 9/9/10.

MR #33: A walk in request for the clinic record was created on 3/1/10 for which it was noted the patient needed the most recent clinic physical. The records were being located on 3/9/10 and ready to review on 3/10/10. It was noted the record was ready to scan on 9/6/10 by the coder. The record was mailed 9/23/10. No explanation of this delay was evident.

MR #34: This electronic request was created on 7/12/10. The records were being reviewed on 7/15/10. On 8/23/10 it was noted the records were on a coding shelf waiting for screening by the coders. On 8/29/10, the records were ready for scanning. Quality assurance and uploading was completed on 9/9/10. The records were mailed 9/17/10 after receipt of payment. The reason for delay in coder screening was not documented.

MR #35: This electronic record was created on 6/10/10. Records were being located on 6/17/10. The storage record was received, attached, and picked up on 8/12/10. No explanation was noted for the delay.


3. Existing medical records policies and procedures did not include a description of the actual process for the research, storage, retrieval, and provision of medical records to requesting parties for all pertinent locations. A flow chart was provided which entailed 32 steps for medical records requisition and tracking, but existing policy and procedures did not include a detailed description of the actual practice for retrieval of multiple records stored at multiple sites. Additionally, The hospital has a hybrid medical record system involving electronic records and paper records. This factor contributes to the time necessary for staff to research and access multiple volumes of records with various patient encounters, which may be stored at multiple sites.
In addition, interview with staff from Radiology on 11/18/10 determined that copies of x-rays, CT scans, and MRI's are provided directly to patients or authorized persons by Radiology. Medical Records correspondence is not notified of the provision of these files. For subpoenas Risk management is notified whereas they are not notified if an attorney requests the films for discovery.
Review of electronic requisitions maintained by the facility's contractor, IOD, determined that multiple duplicate electronic tracking requests for records were created by staff in the requisition of documents, which added additional steps required for staff to sufficiently follow up on requests. It was stated during staff interviews on 11/18/10 that the system does not have an automatic alert to notify the staff that there is a pending request for the same record in process.
It was also determined, based on analysis of the data documented above, that a portion of the delays in processing medical records requests were partly attributed to time elapsed in the process between record retrieval and screening by a coder for record completeness prior to release. During interview with Medical Records correspondence staff on 11/18/10, there are two full time coders available to screen all records prior to release to requestors. A third coder is available part-time. Four or five coders from another office off site perform sporadic coverage.






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Based on review of records and staff interviews, it was determined the hospital did not ensure the accuracy of documentation in patient medical records. Specific reference is made to MR # 18 for an emergency patient whose record erroneously noted a transfer event in progress where none had occurred.

Findings include:

The medical record for this patient who expired in the emergency room during cardiac arrest secondary to MI contained inaccurate documentation which included charting in advance for ambulance transfer and inter-hospital transfer. The record noted that the patient was transported by a paramedic team to another hospital where this event had not occurred.

Review of MR # 18 on 11/15/10 revealed this patient arrived to the emergency department on 6/20/10 for abdominal pain during which the patient was found to have a MI .
-Nursing documentation at 4:46 AM recorded the patient is evaluated for transfer to another hospital as per cardiologist. At 6:36 AM the nurse reported the name of the accepting doctor at the receiving hospital and that the patient is for transfer.
-At 7:27 AM the ALS transfer team was noted to to be present in the emergency room and the patient was attached to a cardiac monitor. The staff notified nursing staff at the receiving hospital about the patient's transportation.
-At 7:36 AM, the nurse documented in the record that the patient is transported to the receiving hospital with two ALS paramedic transport team.
-At 7 :49 AM the same nurse noted "CCU resident was paged prior to transferring the patient to transfer ambulance stretcher and blood pressure not registering, patient is verbal, cool to touch and diaphoretic."
-The patient went into cardiac arrest at approximately 8:30 AM and was pronounced dead at 9:12 AM.

Based on observations and staff interview conducted during emergency room tours, it was evident the hospital did not ensure that confidential patient medical records were kept secure and free from risk of access by unauthorized persons in all locations.

Findings include:

During tours of the adult emergency room by the surveyors at approximately 10:55 AM on 11/15/10, the hospital did not provide appropriate security for confidential patient records which were discovered in a busy treatment area unsupervised by staff. Five patient medical records containing names and confidential patient data were left unattended on a moving tray table in area II. This table was located close in proximity to a row of chairs where unidentified patients and /or visitors were seated. These records were not appropriately secured and protected from view by other patients, unauthorized staff, and unidentified persons passing nearby.
Interview with a nursing staff employee determined he was not immediately present in the area because he had stepped away briefly. He stated these medical records located on the table belonged to patients who were registered and were waiting to be seen by the physician. He reported the records were present on the table because they need to be quickly accessible for review by the physician. However, review of these files determined that one of the patients had already been examined by the MD based on the completion of the health and physical assessment and the patient had already been admitted. A record for a loose EKG belonging to a female patient who was found to have an ST & T wave abnormality was also present on this table.(MR #39)

Refer to MR #s 36, 37, 38, 39, 40.

Based on medical record reviews, it was determined that the facility did not ensure that all entries in the medical record were legible, complete and authenticated (#5, #7, #12, #13,#14, #15).

Findings include:
Review of MR # 15 noted that this patient was a 79 year old patient who was admitted on 9/24/10 after syncope; R/O out Arrhythmia. The physician's progress notes were not consistently legible. The cardiologist progress notes could not be read. The Medical Record Signature sheet located in the record was reviewed. The purpose of this document was to identify the signature of all health care providers in the medical record. Reviewing this document noted that only the nurses ' names were listed; the physicians ' names and signatures weren't located on the list.

Review of Physicians orders noted that the physicians ' signatures were illegible. It was noted that for the medication orders the physicians were required to write their signatures and print their names. It was noted that this was not done.
-This deficiency was noted in MR #s 12, 13 & 14

-Review of MR # 14 noted that the patient was transferred from the hospital on 10/13/10. It was noted that the transfer form was not completed. This form did not indicate if this was an inter-hospital transfer or if the patient was transferred to a skilled nursing facility. It was noted that the reason for the transfer was not documented.

Review of MR #7 noted that this patient was seen in the emergency department (ED) on 9/22/10. It was noted that on 10/5/10, 19 days after the ED visit, it was documented by the physician's that the patient left the ED with out notifying staff or without signing AMA.

Review of MR #5 noted that there were inconsistencies in the documentation in this ED medical record. For example, on 3/26/09 at 4:38, it was documented that the disposition was home. It was documented that the patient was discharge home, on 3/26/09 at 4:38, in good condition. It was noted that the practitioner signed the disposition. However, on 4:49, the nurse noted that the PA (physician assistant) was reevaluating the patient. It was also noted that on 3/26/09 at 4:57, the practitioner noted that about 4:40 the police reported to the staff that the patient recanted her story about sexual assault.

Based on review of medical records , it was determined that appropriate informed consents were missing.

Findings include:
Review of MR # 10 noted that this 17 year old patient was brought to the emergency department (ED) by ambulance accompanied by school aide on 9/28/10 at 14:17. The presenting problems were drug abuse and physical/sexual assault. The patient had a medical evaluation on 9/28/10 at 15:28 and a GYN consultation was requested on 9/28/10 at 16:33. The Consultation - Addendum progress notes indicated that the patient refused rape kit; a copy of the refusal consent to the rape kit was located in the record. However, it was noted that on 9/28/10 at 19:52 the MD noted rape kit was done. It was also noted that on 9/28/10 at 19:10 the nurse noted patient consented to the rape kit. At 20:02, the nurse noted rape kit completed awaiting police.
-Review of Medical Record Sexual Assault Form dated 9/28/10 at 7:30 PM; " evidence collected - rape kit (Y) " was checked off indicating that the rape kit was done. The examining Health Practitioner form was signed by two practitioners. Initially the patient refused the rape kit, it was noted that a copy of the consent form where the patient agreed to the rape kit was not located in the medical record.

- Review of MR # 11 noted that this 15 year old female presented in the ED with allegation of sexual assault. On 8/24/10 at 15:20, the nurse noted that GYN is in ER will be here for rape kit; at 17:21, the nurse noted that the patient refused the GYN exam and rape kit, detectives are in the room; on 8/24/2010 at 18:22, the nurse noted that rape kit was done. The nurse noted that Ceftriaxone won ' t be given because of allergy to penicillin; 2 grams of Zithromax will be given to cover GC-Chlamydia; on 8/24/10 at 18:23, the nurse noted that the patient was seen by GYN, samples collected. It was noted that the consent form for the rape kit was not located in the medical record. It was also noted that the GYN notes were not located in the medical record.

In M R # 16 and MR # 15 the consent for transfer forms were not completed as the benefits and risks of the transfer were not documented. In addition, in MR # 15, the consent form did not indicate if the patient's condition was stable at transfer.

Based on medical record and staff interview, it was determined that the facility did not ensure that all medical record have a discharge summary.

Findings include:
Review of MR # 12 on 11/17/10 noted that the patient was admitted on 10/10/10 and expired on 10/15/10. It was noted that a discharge summary with outcome of hospitalization and disposition was not located in the record.

The facility's staff interviewed on 11/17/10 reported that this document was not completed.

Based on record review, review of policy and procedure and interview, it weas determined that the hospital failed to ensure the the proper identification of laboratory pathology specimens. (#1)


Findings include:

There was evidence that the pathology reports of both patients in MR# 3 and MR# 4 were inaccurate. As a result, one patient was diagnosed with cancer in error. Specific reference is made to the evidence below.

Review of MR# 3 on 11/15/10 found a surgical pathology report that definded the tissue submitted at operation as a " breast mass with margins ( right ). " In the gross description portion of the report reference is made to a " J " shaped wire inserted within the specimen. The diagnosis was noted as invasive ductal carcinoma, well differentiated. Review of the operative report found no reference to " needle localization. " Review of the operating room schedule found no reference to needle localization.

Review of MR# 4 on 11/15/10 found reference to needle localization in the pathology request as well as the OR schedule. However, in the surgical pathology report, there is no reference to the presence of any needle or wire in the specimen. The diagnosis of the specimen was fibromatosis.

Revised surgical pathology reports were submitted 2 months later that placed each report under the proper patient name and medical record number.

At interview with the Director of Pathology on 11/15/10, the error was acknowledged but the root cause could not be identified by the investigation. The process in place involves the surgeon, scrub and circulating nurses, transporters, clerks, and finally pathologists.

There was sufficient evidence at the time of the review of the specimens by the pathologists to warrant deferring the report and confirming the identity of the source, notwithstanding any mislabeling. Specifically, the diagnosis of ductal carcinoma for an 18 year old as well as fibormatosis for a 75 year old are both rare. Furthermore, the presence or absence of a needle/ wire in the specimen that does not correspond to the requests, operation or reports should have warranted further confirmation of the identity of the patient.

Based on review of medical record and facility's policy, It was determined that the hospital did not ensure that all emergency requirements were met so that all patients arriving in the emergency department (ED) for treatment receive appropriate medical care.

Findings include: -Review of MR #5 noted that this 17 year old female was brought to the ED 3/26/09 at 0:29 AM. The chief complaint was assaulted and raped. The triage nurse noted "patient brought in by mom. Patient crying stated that she was assaulted, hit on her head, was raped, and assaulted". The nurse noted + mild swelling and tenderness of the forehead, painful on touch c/o of headache. On 3/26/09 at 4:39, the nurse noted that the patient recanted her story that she was assaulted and raped.
This patient had a medical evaluation on 3/26/09 at 1:30 AM. During the physical examination, the provider noted that the patient had minimal bruises to her forehead. The patient was reassessed at 4:57 AM, the provider who reevaluated the patient noted " at about 4:40 AM the police reported to us that the patient reported to them that she had made up this story; because she had not gone to school " . The patient was discharged to home. It was noted that the bruises on the patient ' s forehead was not addressed with the patient prior to discharge; how the patient obtained the injury was not explored.

Review of MR # 6 noted that this 16 year old patient was brought to the ED by ambulance on 4/5/10 at 21:40. The chief complaint " my dad hit me with a broom & stapler " . The triage nurse noted that the patient had abrasion to left cheek, abrasion to right 5th digit, + hematoma to the back of the head. -The ambulance report indicated that the patient had swelling to the cheek and abrasion; patient also had a bump to the back of her head, pain to the right thigh positive redness, abrasion to left pinky, bump to back of head.
-This patient did not have a complete medical evaluation as the assessment did not include if the patient had any marks bruises on her body (old or new). The assessment did not include the abrasion to the cheek or the bump in the head.
- It was documented that the parent who hit the child was arrested. This patient did not have a forensic examination as no photographs were taken or the reason why this was not necessary.

Review of MR # 17 noted that this 13 year old arrived in the ED on 4/28/10 at 19:09. The triage nurse noted that the patient stated that she was punched in nose by her mother. It was noted that this patient was placed in triage category ESI -3 urgent. -On 4/29/10 at 15:10, the physician noted that the patient walked out without being seen. It was noted that this patient was placed in the incorrect triage category as according to the facility ' s triage policy all victims of child abuse are to be placed in ESI 2 triage category.

Review of MR # 7 noted that the patient arrived in the Emergency Department (ED) on 9/22/10 at 1:34 AM. The chief complaint was vomiting associated with black and green diarrhea. The patient was triaged on 9/22/10 at 1:40 AM. The disposition was left with out being seen. The physician noted that the patient left without notifying staff or without signing out AMA. It was noted that the time and date of the documented was 10/5/2010 at 7:23; 19 days after the patient was seen in the ED.

Review of MR # 8 noted that this patient arrived in ED on 9/22/10 at 6:46 AM; the chief complaint was headache (pain scale 7-8), vomiting & diarrhea. The patient was triaged on 9/22/10 at 6:47 AM and placed in triage category ESI 3. There was no evidence that this patient had a reassessment or medical evaluation. The time that the patient was called for an evaluation was not documented. The disposition of this encounter was not documented.

Review of MR # 9 noted that this patient arrived in the ED on 9/22/10 at 6:40 AM. The chief complaint was coughing & fever. The patient was triaged at 6:40 AM; there was no triage category noted on the record. On 9/22/10 at 8:01 AM, the nurse noted that the patient did not want to change clothes, stating that she only had a common cold. There was no evidence that the patient had a medical evaluation. The disposition on 9/22/10 at 10:46 AM was left without waiting notifying ED staff. This patient was placed on the ED log as AMA - leave against medical advice. This was incorrect as the patient was never seen by a physician.

Based on review of medical record, facility's policy and other documents, it was determined that the facility did not consistently ensure that emergency services were integrated with other departments.

Findings include:
Review of MR #5 noted that this 17 year old female was seen in the ED on 3/26/09 at 0:29 AM and discharged at 4:38 AM. The patient reported that she was assaulted and raped; stating she was taken by some guys in a van when she got off school at 3:00 PM. This patient later recanted her story to detectives and hospital staff. This patient required a complete psychosocial assessment for a proper intervention.-There was no documentation that social consultation was done while the patient was in the ED. There was no documentation that ED staff offered this service to the patient/the patient ' s parent, while the patient was in the hospital.

-The Emergency Medicine Social Work Support policy was reviewed. This policy indicated that social work assistance is available after working hours by telephone. There was no documentation that this policy was followed.-This patient was discharged from ED without having a complete assessment.

On 3/26/09 at 11:12 AM, SW intern noted " read nursing notes patient was discharge home with mother and boyfriend " . SW intern noted patient was called but unable to leave message; SW intern will mail case closed.
Copy of the letter dated 3/30/09 that was sent was reviewed. It was noted that this letter was addressed the patient ' s mother. This patient ' s required needs and services were never addressed.

Based on review of procedures, observations, record reviews, and staff interviews, it was determined the hospital did not develop and implement complete procedures that addressed the safe disposition, proper documentation, appropriate chain of custody, and destruction of sexual offense evidence collection kits in the emergency room.

Findings include:

1. The hospital's policy for maintaining sexual offense evidence was incomplete in that it did not describe the appropriate chain of custody to be followed for refrigerated sexual offense kits. The procedure noted that security would be responsible for non refrigerated items and did not identify the staff responsible for refrigerated kits or describe who has responsibility for the keys . Procedures did not limit staff access to this refrigerator where these items were stored in order to maintain a proper chain of custody.
During tours conducted of the adult and pediatric emergency room on 11/15/10 at approximately noon, it was discovered that chain of custody for sexual offense kits was not properly maintained. Specifically, the keys used to access the locked refrigerator located in the pediatric GYN examination room utilized for the storage of sexual evidence kits was maintained on the narcotic key chain by multiple nursing staff. It was stated during interview with the charge nurse on that date that the keys are used by nursing staff on a daily basis to access the refrigerator where kits are stored in order to record the temperatures. Review of the document entitled "Daily refrigerator temperature log" on 11/15/10 confirmed that daily temperatures taken of the refrigerator used for rape kit storage were recorded by different staff on a daily basis throughout 2010.

The daily unlocking of the refrigerator by multiple nursing staff was not reflected in the policy for sexual assault and was not limited to appropriate staff for chain of custody requirements.

In addition, it was stated during staff interview that non-refrigerated items are kept in a paper bag in the cabinet in the pediatric GYN room and was not maintained by security staff as required by the hospital's procedure for maintenance of non refrigerated sexual offense evidence.

2. Sexual assault procedures for maintaining evidence did not describe the method for destruction of rape kits after 30 days. The sexual offense evidence kit log maintained inside the locked refrigerator was incomplete and did not include documentation of the method of destruction of rape kits or the staff responsible. The log did not consistently differentiate between adult and pediatric patients and did not include all relevant data as noted above. While sexual assault procedures describe the victim is to be notified of destruction after 30 days, there is evidence that this process was not followed. Specific reference is made to MR # 41, for a patient whose kit was destroyed on the same date that it was collected (4/2/10).


Based on review of records and emergency department procedures for victims of abuse, it was evident that the hospital did not implement effective practices for the provision of sufficient medical care that met standards of emergency care for identified patients.
Findings include:

Five of twelve (12) emergency department records sampled for victims of alleged child abuse or sexual assault did not demonstrate compliance with standards of care.


Examples:
MR #42:
This medical record for a child who presented to the ED for alleged sexual abuse did not demonstrate evidence of a medical screening examination. The facility allowed the child to be removed by law enforcement officials prior to completion of a hospital medical examination.
This 4 year old female child presented with her mother in Police custody to the ED on 2/5/10 with a chief complaint reported by the mother that the child had told her that her grandfather had touched her "down there" on 1/16/10 while babysitting. The nurse conducted the triage assessment at 13:31. It was also noted that the domestic violence assessment noted "NA". No rationale explaining this entry was evident. The patient was classified as ESI-3 -urgent.

At 13:31 a nurse documented in the electronic record that the patient was received with the mother and a Police officer from the 102nd precinct. It was noted the patient had left with a detective (identified by name) who brought the child to their clinic to be examined.

The medical section entitled "history of present illness" recorded that the 4 year old female "presents with waiting evaluation. The patient was never registered or examined in the ED. The Detective from the Special Victims came and stated that the child will be examined by their clinic." The patient was taken by a detective (name and number listed). The box was checked which denoted "vital signs /triage/nursing notes reviewed and agree." The section for physical examination was blank. The medical record contained a disposition note entered by the physician at 1815 that the child "left without being seen." Diagnoses listed were "waiting evaluation" and the secondary diagnosis noted was "asthma".

No medical screening assessment, discharge orders, nor transfer summary were evident. The record was inaccurate because the patient was noted to have left without being seen but rather had been removed by law enforcement for a proposed medical examination at the Special Victims clinic. The delegation of the medical examination to an outside forensic provider did not preclude the need for hospital medical assessment.

The child abuse log noted "??" under the section labeled as disposition for this patient.

The hospital's policy and procedure for Child abuse and Prompt Response protocol notes the need to report to Special Victims Squad detectives but does not include any practice governing removal of children by law enforcement personnel from the ED after triage and prior to completion of a hospital medical assessment.


MR #43:
The hospital did not appropriately manage the care of this 15 year old female, who presented to the ED for alleged sexual assault and for whom it was determined she was restrained by Police and hospital staff for reported assaultive behavior to Police while receiving treatment.

The patient was brought to the ED by the foster mother on 1/23/10 at 2020. The foster mother reported the patient ran away the day before and came home one hour prior to arrival with complaint she had been raped in Brooklyn at 3 AM that morning. The Foster care agency supervisor was contacted to confirm the diagnosis and medication.
On 1/24 at 12:20 AM the rape kit was completed by GYN.
On 1/24 at 1:19 AM the nurse noted the patient became upset and refused to stay for further care due to questioning by the detective. The patient requested the IV to be removed and refused treatment. The foster mother stated the patient has bipolar and schizophrenia, and has not taken prescribed medication. The mother requested psychiatric admission and stated she runs away when she gets upset. The patient was restrained by NYPD. No further explanation was noted by the nurse or MD for this event.

At 2 AM a handwritten MD restraint order was written for posey, 4 limbs and four side rails up restraints. The order was incomplete and failed to document time limit, duration, or reason for restraint . No alternatives to physical restraint were noted. Additionally the medication order record showed at 2:11AM, the patient was also given an IM injection of haldol 5mg, benadryl 50 mg, and ativan 2 mg. No rationale was recorded for the use of these drugs, which constitute a concurrent use of drugs used as chemical restraint. The assessment flow sheet portion of the restraint form noted that the restraints were monitored every 30 minutes from 2 AM to 6:30 AM. This was in contradiction to electronic record nursing documentation which noted the patient was in Four point restraints and posey at 7:16 AM. There was no documentation to indicate the time the restraints were removed.

On 1/24/10 at 4:32 AM , nursing noted the patient was asking to have the restraints removed. The RN noted the restraints could not be removed due to the patient being on 1:1 watch.

Additionally physician's handwritten restraint orders were in contradiction to electronic medical orders noted at 1/24/10 at 6:25 AM in which the medical orders noted patient was placed on 1:1 observation at 2 AM and that 4 point restraints (soft) were ordered at 6:25 AM. It was noted the 4 point restraints were placed at 2 AM when the patient became uncontrollable. The electronic order was incorrect as it was evident from the record the patient was actually placed in 5 point restraints and 4 siderails.

On 1/24/10 at 2:30 AM the psychiatrist documented an assessment of the patient in which it was recommended the patient receive one to one observation for unpredictable behavior and Abilify. Inpatient psychiatric admission was recommended. The patient received two follow up psychiatric assessments. The last reassessment on 1/25/10 at 10:20 AM noted that after she had been examined she had tried to leave the facility and allegedly assaulted a Police Officer. As per the patient's account she was handcuffed because she did not want to be with her foster mother. The psychiatrist also noted, " the patient's affect appears euthymic; not representative of alleged rape victim or who allegedly assaulted cop".

The patient did not receive timely medication administration as ordered. An order for Abilify at 7:10 AM on 1/24/10 was sent to the pharmacy at 7:45 AM but was not given until 1:20 PM. The patient was transferred to another hospital for inpatient psychiatric admission on 1/25/10 at 3:23 PM.

This case failed to meet standards of care for the following reasons:
-The patient was physically restrained in the emergency room both by Police and hospital staff without appropriate orders or sufficient monitoring following an event of alleged assaultive behavior.
- The staff allowed the patient, who was allegedly sexually assaulted, to be handcuffed by Police while she was a patient. There was no evidence of the duration of the Police restraints or record when the handcuffs were removed.
- The patient was placed in five point restraints (4 limbs and posey) in addition to use of 4 siderails. Orders were incomplete and did not include the time limit or rationale for its use. Documentation of alternatives attempted to restraints was lacking.
The patient was not monitored at appropriate Q30 minute intervals by nursing staff. The patient remained in restraints even after the nursing restraint flow sheet record had ended at 6:30 AM.
-The nurse also refused to release the patient from restraints upon the patient's request, on the grounds she was on one to one watch.
This justification for continuation of restraints was inappropriate.
--The hospital ' s emergency room restraint policy was incomplete in that it lacks a forensic procedure for monitoring of patients in simultaneous hospital restraints and forensic restraints, i.e., handcuffs. Following removal of restraints, there was no documentation the patient was assessed for response, range of motion, circulation, and other parameters as defined by the policy.
--Additionally, the ED Restraints Policy did not adhere to standards of practice in that during emergency application of restraints, the procedure allows up to eight hours duration for the physician to document a restraint order. This is contrary to regulatory requirements and standards for safe care.
-Nursing and MD notes did not disclose the details of the alleged Police assault other than the Police had restrained the patient. No explanation had been concurrently noted which resulted in this event. The only reference to the event in the record was documented in a follow up psychiatric assessment dated 1/25/10 which noted the patient had reportedly assaulted a Police Officer in the ED and stated she was handcuffed.
-A bitemark was identified by the gynecologist during the kit collection and that the patient denied it. The location was not recorded or photographed.
-There was no evidence of discharge medications recommended on transfer.
-There was no evidence the patient or guardian was contacted in advance of the rape kit destruction. The rape kit refrigerator log noted contradictory information with two different dates of destruction. The log documented the kit was destroyed and not picked up on 3/2/10 and 6/1/10.


MR #44:
This pregnant victim of alleged sexual assault remained in the emergency room for more than 2 days waiting for shelter. The patient was discharged without complete examination and no disposition or referrals other than to OB/GYN clinic were noted.
This 20 year old female was brought to ED on 7/24/10 at 7:02 AM by ambulance with complaint of having been beaten with a chain following abduction by 4 males. The patient reported she was hit with the chain and dragged to a building. She awakened in an abandoned building and was disrobed. Multiple bruises were noted across body (ecchymosis to left orbit, shoulder, legs)
Patient underwent repair of right leg laceration. The medical record was incomplete; despite reference to completion of GYN consult and rape kit, the consultant's report was missing from the record. Incidental finding was identified the patient was pregnant. It was noted at 1920 hours on 7/24/10 the patient could not go to a shelter that night and would be held until the next morning. A referral was placed in the Social Work Log book at 1902, No labs for results of CT scan of facial bones was evident. No documented evidence hepatitis C testing was provided following assault.
On 7/25/10 at 1228 it was noted the patient was waiting for placement in a shelter.
At 10:36 AM on 7/26/10, it was noted the patient was seen by the social worker .However, no social work consultation was included in the record. No final discharge disposition for housing or other referrals were noted other than reporting to OB/GYN clinic in 2 days. There was no evidence the hospital staff attempted to obtain patient consents despite not being able to do so at the time of arrival due to eye swelling.


MR #45:
A safe environment was not provided to this 4 year old child who was removed from the ED by an angry parent during examination. The facility did not ensure appropriate supervision or monitoring when it was noticed the mother became agitated.
This 4 year old male was brought in by ambulance to the ED on 4/6/10 at 2313 secondary to sustaining 2 upper arm lacerations which exposed fat tissue following a dog bite by family dog. Patient triaged as ESI 3 urgent at 2313. At 2353 the patient was assessed by the MD. At 0030 (12:30 AM), the patient was assessed by the pediatric surgery consultant. Parents were unsure if dog was vaccinated and the father went to obtain paper work. The child noted to be autistic. The wound was irrigated copiously with NS and sharply debrided at the edges. It was then noted that "at this point, the mother removed the child from the pediatric ED." The Police and Security was informed and the MD noted a call back was pending from another MD. It was noted at 0049 (12:49 AM) on 4/7/10 the mother was extremely agitated on arrival to the ED and that staff was not attending to her child . She told staff to cancel the registration and that she was leaving. In the interim the surgical resident advised the patient that a consult with the attending was needed and would return shortly. The mother stated she wanted to leave to go to another hospital and was advised she could not leave because the child needed treatment. Security was called but the mother took the child and walked out of the ED. NYPD was called and ACS. A call back was received that the child and mother were at another hospital. ACS was notified of this update. However a nursing note at 12:22 AM on 4/7/10 indicated the patient was seen by surgery and walked out of the ER after becoming upset. Security was notified but unable to retrieve the patient and mother. The hospital did not ensure a safe environment for security one to one upon noticing parent agitation. Contradictory information was noted with respect to whether the dog was vaccinated. No evidence of report was made to the Department of Health as required by hospital procedure for animal bites.


MR #46:
This 2 year old male evaluated for anal trauma secondary to suspected sexual abuse did not receive a complete exam and the record did not explain if ACS had cleared child for discharge.
The child was brought in by his mother on 6/17/10 who reported sexual abuse allegation. The chief complaint was reported that the child was screaming for help and when queried for hurting, the child pointed to his behind and said his "daddy did it." After this the child grabbed his 1 year old cousin and started humping him from the butt.
Child was triaged as ESI 3 urgent.
The child lives with the father and paternal grandmother. The mother was unsure who might be responsible but thinks sexual abuse could have occurred in the father's home. Case was reported to ACS, who advised social work they "have no jurisdiction over the child due to well baby visit". No further rationale for this lack of intervention was noted. The child was discharged with the mother with ACS worker attendance noted in the ER. A clear statement of clearance for discharge by the ACS worker from the ER was not documented. The child abuse log noted "?? " for disposition.
Exam revealed no evidence of trauma on genitals or rectum. Only a stool culture was performed which was negative for salmonella, shigella, campylobacter. There was no evidence of any other tests performed , including blood work or other tests including GC, syphilis, anal swabs, or other evidentiary collection requirements.





16140


Based on review of ED policies and procedures under Emergency Room Services - Policy and Procedure Manual and interview it was determined that the facility promulgated policies and procedures regarding the triage of patients in the psychiatric ED that as written describe a process that has the potential for delay in the triage and assessment process.

Findings include:

Review of the policy referenced above on 11/15/10, reviewed in 6/08, which describes the adjudication of " disputes " in the disposition of patients who present directly to the psychiatric ED, the following directives were noted:

Reference (i) states that all triage by the nurse occurs only following a security check. It does not describe the role of the nurse during the check. Reference (ii) there is a note that if upon assesment the patient requires treatment in the main ED, the triage nurse will consult with the triage nurse in medical ED to " request " a " transfer " to the ED. Reference (iii) states that if the medical triage nurse is " agreeable " the patient will be escorted to the ED. Reference (iv) states that it the two triage nurses are " unable to come to an agreement ", the " dispute " will be referred to the attendings on each of the respective emergency services for " resolution ". Reference (v) states that once a patient is " registered " in either ED, the patient must be transferred to the other service only by " prior agreement " between physicians on each service, usually by consultation. Reference (vi) advises staff that " differences in opinion concerning triage or transfer are to discussed out of public view. "

At interview with the Nursing Director covering Psychiatry, it was stated that this policy is not in effect and that nurses are to accept the patient and commence any stabilization as required in collaboration with the physicians, that patients who arrive by EMS are not subject to the dispute resolutions referred to above and that there is no triage nurse to triage nurse transfer agreement.

Based on record review and interview, it was determined that the facility formulated a policy and procedure that referred to a directive that had the potential for patient harm.

Findings include:

Review of Emergency Department (ED) policy and procedure (page 201) titled " Military Personnel " on 11/15/10 stated under the word policy that if any member of the military is in need of emergency care, Monday through Friday from 8:00 AM until 3:30 PM, a military patient or family should be referred to the Outpatient Department of a military hospital. At all other times, " treat patient and/or family as appropriate. "

At interview with the ED Medical Director on 11/15/10, it was stated that this " policy " was an error and that no such practice exists and he was unaware of this reference.

Based on review of ED Policy and Procedure reviewed in 2/08 titled " Surgical Procedures " -Handling of Bullets, there is no evidence that the facility formulated a policy and procedure to ensure that bullets recovered from gunshot wound victims in the ED are transported to the pathology lab in a manner that does not contaminate the evidence.

Findings include:

Review of the ED Policy and Procedure referenced above does not specify the type of " container " used by the transporter to the lab. It further does not mandate that the person from whom the transporter received the bullet be identified. The policy does not require sequestration of the bullet immediately after recovery in the ED setting to ensure that the chain of evidence is not broken.

Based on record review ( policy and procedure ) , interview and observation, it was evident that the ED maintains a 2 tiered triage system ( formal and informal ), and that no record is kept of those patients who present for emergency care but do not wait for the " informal triage ".

Findings include:

Review of triage policy and procedure does not note the presence of the " informal triage " nurse who sits in a booth in the waiting room. At interview with this nurse on 11/15/10, it was stated that she notes the complaint and name and decides if the patient can wait for " formal " triage and that she enters this information into the computer. No vital signs are taken.

There is , however, in the triage policy and procedure in section I (D) reference to that when a patient walks into the ED entrance. he/she goes to the triage booth and tell the triage nurse the chief complaint. If the patient is judged to have a non life threatening or non emergent condition, the nurse records his/ her name in the triage log, and advises the patient to wait for " formal triage. "

At interview with nursing administration 11/15/10,.it was stated that the " list " of patients who do not make it to the " informal " triage part of the process is discarded and therefore, no record of the attempted encounter is maintained.


The triage sign in list is not maintained after the day to determine the number of patients who walk out prior to " informal " triage.



Based on record review and interview, it was evident that the emergency department medical staff did not ensure that a patient who had a history of dysphagia was properly ruled out for the presence of a retained foreign body.

Findings include:

Review of MR# 2 on 11/15/10 found that the elderly patient (93 years old) with ongoing dysphagia presented to the ED with complaints of a foreign body sensation in the throat after eating. CAT scan was inconclusive and ENT consulted, but no efforts to explore areas of of the throat where a particle of food might be retained but not visible on CT were done. 48 hours later a piece of lettuce was recovered from the patient's hypopharynx during EGD. It apparently adhered to the portion of the mucosa and was not obstructive per se but contributed to the excessive salivation documented in the medical record.

At interview with the ED medical director it was stated that the EGD was not emergent in that the patient had a history of dysphagia, motility issues, and was able to swallow saliva despite any discomfort. It was stated that even after the removal of the " lettuce", the patient continued to complain about the foreign body sensation. There was no note as to what could have occurred if this lettuce disadhered from the mucosa and obstructed or was aspirated.



16790


Based on the facility's Emergency Medicine policy, it was determined that the triage policy did not address the severity of patients seen in the emergency department.

Findings include:
During site visit on 11/17/10, a copy of the facility's triage policy was submitted. The Emergency Medicine Triage policy revised on 1/10 was reviewed. This policy indicated that the facility's Emergency Department utilizes the Emergency Severity Index (ESI) 5 level triage algorithm. A copy of the policy submitted did not include examples for patients placed under ESI level 3 category.