HospitalInspections.org

Based on review of policies , QAPI records, and staff interviews, it was determined that the hospital did not revise policies and procedures which pertain to Emergency Medical Treatment and Active Labor Act ( EMTALA) and did not ensure that staff had updated training in this topic since 8/29/08 and 9/19/08.

Findings include:

Review of hospital emergency department procedures on 10/7/10 determined that the policy entitled "Emergency Medical Treatment, Screening and Stabilization, and the Transfer of patients to other Facilities for Diagnostic Procedures and Treatment" was not reviewed or revised since it went into effect on 3/24/98. Based on interview with the facility administrative staff on 10/8/10, there was no evidence this procedure was updated.

Staff interview and review of Emergency Department QAPI meeting minutes dated 8/29/08 confirmed that EMTALA training was provided to ED staff on 8/29/08. However, the list did not reflect participation by all staff and disciplines, including security staff. No description of a detailed training curriculum covered was referenced during this meeting. While interview and review of ED QAPI meeting minutes for 9/19/08 revealed education for EMTALA had been provided on 9/19/08, there was no sign in sheet available to reflect staff that were present.

It was confirmed during interview with the facility Vice President on 10/8/10 that no follow up EMTALA staff training was conducted since 2008.

Seven of seven employee files reviewed on 10/7/10 for medical, nursing, and security staff working in the emergency department lacked any evidence of ongoing training for EMTALA requirements.
Refer to employee staff files #s 1-7.

Based on tours and observation conducted of the emergency department on 10/4/10 and 10/6/10, it was determined the hospital failed to ensure conspicuous display of signs that specify the rights of patients to examination and treatment of emergency conditions and for women in labor in accordance with Section 1867.

Findings include:

Tour of the ED walk in entrance and waiting room at approximately 11 AM on 10/4/10 revealed inadequate display of signs required which notify participants of their rights to examination and treatment of emergency medical conditions and which also apply to women in labor. Two signs were displayed on 8 ? X 11 paper in English and Spanish, which were affixed to a glass window that encloses the triage booth and registration areas. These signs were posted on this window located above a ledge where a clipboard is maintained for walk-in patients to sign in upon arrival. The signs were not displayed prominently at eye level and contained small print. No signs were present or posted in the waiting room seating area nor in the ambulance entrance. No signs were posted in admitting or treatment areas as required.

Based on review of the emergency department central log (ED log) it was determined that the facility did not ensure that it had a complete and accurate ED log as required.

Findings include:

Review of the emergency department (ED) log on 10/5/10 revealed multiple instances of incomplete entries, with respect to documentation of vital patient information or disposition.

For example, MR #18 for a patient who presented to the ER four times on 9/7/10 revealed no documentation of this patient's disposition following registration time recorded for the 9:30 PM registration time encounter.

The ED log dated 6/2/09 omitted the disposition or outcome for a patient. This encounter listed the name of a 55 year old male patient with a diagnosis of body aches with a noted registration time of 12:24 PM. Follow up documentation received from the facility on 10/19/10 revealed the medical record for this patient was not found.




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A review of the log noted that 7 patients had no recorded dispositions on the following dates ( 8/1/09, 8/4/09, 8/14/09, 8/10/09, 8/17/10, 8/27/10 & 10/6/10); it was also noted that one entry on 10/5/10 documented a registration number but no other patient information or disposition was recorded.

Based on review of emergency medical records, procedures, and staff interviews, it was determined the hospital did not provide complete medical screening examinations to patients presenting for emergency care. Medical screening exams did not consistently reflect interventions and plans to address patients' presenting problems. This finding was evident in 10 of 65 emergency medical records reviewed. Refer to MR#s 1-10.

Findings include:

-Review of MR #1 on 10/4 and 10/8/10 revealed systemic failures in the management of this 48 year old male who presented to the ED via ambulance on 6/28/09 at 12:45 AM with acute alcohol intoxication and head trauma. Despite the presence of a head abrasion as noted on the ambulance patient care report, this patient did not receive a complete medical screening examination for head trauma nor proper monitoring of the head injury. This resulted in delay in appropriate treatment of a head injury. The medical assessment was not recorded until 2 AM and orders were not timed or initiated promptly. Despite the presence of a head abrasion, history of fall, highly elevated ETOH blood level, disorientation, and evidence of decreased neurological function based on a decreased Glascow coma Scale (GCS) score of 12, CT testing of the head was delayed for more than five hours following the patient's arrival to the ED. There was a significant delay in provision of diagnostic radiology testing for CT of the head, which was not ordered until 5:52 AM and subsequently completed at 6:23 AM. Additionally, despite inconsistencies in the circumstances of the patient's head injury prior to arrival, highly elevated alcohol level, symptoms of compromised neurological function, the completion of a neurological consultation was not documented. The patient was subsequently found to have intraparenchymal, intraventricular, and subdural hemorrhages, which required emergency intubation for airway support and transfer to another facility for neurosurgical intervention at approximately 8 AM. Brain death was declared two days following surgery performed at the receiving hospital on 6/30/09.

The pre-hospital ambulance report in the medical record revealed this patient arrived to the hospital via ambulance at 12:38 AM on 6/28/09 where he was found intoxicated and unresponsive in front of a bar. A patron reported the patient may have fallen. Prehospital care ambulance documentation recorded the patient was alert and oriented x 1 to name, belligerent, and noted to have abrasion to the head. He was disheveled with slurred speech. It was noted the patient was responsive to pain and " could speak for short periods of time before passing back out " .

The patient was triaged as urgent by the nurse at 12:45 AM on 6/28/09 in the ED where it was noted he "pass out on the bar - ETOH- had". Beneath the chief complaint it was written " abrasion/knot to head " . The patient was placed in room #6.
The nursing assessment was untimed, and noted " unable to contact family " . He was responsive only to pain and was recorded to have told EMS " I don ' t remember - leave me alone " .

The physician assessment was documented at 2 AM on 6/28/09. The form utilized was a T- form template for head injury. Notation indicated " ETOH with head trauma " and fall was circled. The word abrasion was noted next to a diagram of the head, which denoted an "x" mark to the back of the head. Left and right pupils measured 3 mm. The patient was disoriented . Glasgow coma scale score was recorded as 12 but scores for subcategories were blank. Cranial and cerebellar fields were normal but decreased deep tendon reflexes (DTRS) was noted. X-rays and procedures were blank. The assessment noted " ETOH abuse -485 and Intracranial/subdural bleed. " CT of the head noted intracranial and subdural bleed. Subsequent interview of the MD (staff #3) on 10/12/10 determined the information about the intracranial bleed was added to the form by a different physician (Staff #1) after his shift had ended. There was no documentation present to explain the discrepancies in circumstances of the injury prior to arrival on this assessment form when compared to the ambulance report.

A physician's order form was signed by staff # 3 but not timed. These orders included pulse ox, fingerstick glucose, EKG, cardiac monitor, foley catheter, intake and output and neuro checks Q 1 hour. Labs for CBC, BMT, LFT, urine tox and ETOH were also ordered. Neurological checks had not been conducted hourly and other than the ETOH level performed at 2:20 AM, all other diagnostic tests were recorded after 6 AM, around the time the CT was ordered for the patient's continued level of unresponsiveness.

Documentation by the nurse at 2 AM noted the patient was "asleep and pending observation" .
At 3 AM it was noted the patient was "asleep for sobering up in AM."
At 4 AM nursing noted the patient was asleep.
At 5:30 AM it was noted the patient was "reevaluated- still unresponsive and sent for CT scan."

It was determined that the Head CT scan was started at 6:08 AM and completed at 6:23 AM. The report noted "intraparenchymal and large subdural hemorrhage with significant mass effect with right midline shift. Intraventricular hemorrhage was also present along with a right occipital scalp hematoma. Opacification of the right maxillary sinus was identified that was suggestive of a fracture of the right orbit or maxilla." It was noted that additional imaging could be requested as clinically indicated. C-spine had revealed no evidence of fracture.

Physician critical care continuation T form by the relieving MD (staff #1) at 0600 AM noted that the patient was "minimally awake, alcohol on breath, and moving extremities x 4 with abrasion to the right parietal/occipital abrasion". The " patient was found in a bar post fall -waving off EMS " . ETOH was (485) and on reassessment at 0530 hours the patient was snoring and unable to awaken. The CT scan results were noted. At 0600 a neurological record documented patient was semi comatose . The GCS was checked no verbalization, no eye opening, pupil size =4 bilaterally, and fixed right and left pupil reaction. The patient was intubated for airway protection at 0630 hours and managed medically until transfer by ambulance.

At 0715 AM the patient was accepted by the MD at another hospital. The patient was transferred via ambulance on ventilator at 0845 AM on 6/28/09. Authorization for transfer was not signed by the responsible party because the family was not available and there was no answer on the phone. The ER transfer form noted " family called- waiting for call back- info on chart. " There was no evidence the hospital successfully notified the patient ' s family of his condition and transfer plan . There was no evidence of follow up efforts to contact next of kin following transfer.


Interview with the nurse (staff# 5) on 10/6/10 at approximately 3 PM revealed the patient arrived on 6/28/09 in an unresponsive state. The employee acknowledged he was unaware of a head abrasion on arrival and added this information to the triage documentation later on.
Only a verbal report was received on arrival from the paramedics, when it was communicated that the patient was intoxicated and picked up at the bar for passing out. EMS advised that the patient told them to leave him alone. The nurse confirmed he could not interview the patient, who was unresponsive. During further inquiry, the nurse stated he was unaware of the bump on the head initially and added documentation of head knot and abrasion to the triage section after speaking with the MD because he did not know where else to document this information. The nurse stated a written ambulance report was not received for 3-4 hours and reported that there is frequently a delay in receipt of patient care records from the ambulance company. Following arrival, the nurse placed the patient in a room located in the back of the ED usually utilized for patients in respiratory isolation. This room, #6, was located in the rear section of the ED and was not visible to nursing staff. (Surveyors observed during tour on 10/5/10 that this unmonitored room was located at a proximity of about 14 feet from the nursing station). The nurse stated he just let the patient sleep off the alcohol and he did not want to wake the patient up because intoxicated persons can become violent when awakened. The nurse acknowledged he did not perform a mental status exam on the patient. At around 5 AM he spoke with the MD because the patient was not improving and the patient had never awakened. At that point the CT was pursued but he recalls it may have taken awhile. The CT report identified the hemorrhage around that time.

Interview with the physician, staff #3, on 10/12/10 at 3 PM revealed the patient's mental status was alert and combative, which differed from information as reported by the nurse during interviews. He stated emergency ambulance staff verbally informed that the patient had fallen off a stool in the bar and there was a bump on the head. He did not see the written ambulance report in the record and stated these documents arrive later (the ACR on the record indicated the patient was found outside of the bar). The physician saw the patient upon arrival and the patient was yelling and cursing. He stated while the ambulance staff told him the patient fell off a stool and he noticed a bump on the head, he did not think he make a note of this in the record. The patient walked himself from the stretcher to the bed in the ED. The patient was yelling to leave him alone and was combative. He noticed the bump on the head but the pupils were equal and the patient was moving all his extremities. He told the nurse to keep a close eye and check on the patient "every now and then " . He requested the nurse obtain bloods and a CT scan. He thinks he advised the nurse to check the patient every half hour or hourly. He did not think he wrote monitoring orders for the nurse at that time. He again saw the patient 30 minutes later and the patient was arousable, talking, but made no sense. The patient was reportedly uncooperative.
The physician was aware of the alcohol blood level of 485 at 2 :20 AM. He did not interview the patient but recalled the patient said his head hurt. The patient was disoriented. Pupils were equal. He acknowledged the GCS score of 12 but did not document a score for each sub-category. The patient had a good gag reflex but acknowledged a cerebellar exam was not performed because the patient could not stand straight or follow commands. The physician acknowledged this information was not recorded in the medical record.

Additionally the physician reported on interview that he saw the patient upon arrival to the emergency room and several times afterwards but only recorded one assessment note, on or around 2 AM. ;he reported he was busy working with other patients. At approximately 2:20 AM, he observed the patient in the same condition, who was sleeping on and off and was non responsive to pain. He saw the patient again sometime after 2:20 AM and before 6 AM. The patient was lethargic but arousable. The physician stated that he told the nurse to do a CT scan of the head as soon as possible. Before 6 AM the physician saw the patient was less responsive and was not talking; the patient made sounds but made no sense. The pupils were still but the physician did not recall documenting this observation. The CT scan was performed around 6 AM. Following the discovery of the hemorrhage, he endorsed this case to his Director (staff #1) due to shift change. The plan was discussed to transfer the patient to another hospital for neurosurgical care. The physician acknowledged he did not call for any neurosurgical on call consultation and was unsure if his Director had called for one after he left.

The physician reported he waited for the CT scan because he would have had to medicate the patient for this test. The patient was too intoxicated to cooperate. His plan was to wait until the patient became more cooperative because it was too dangerous to give medication in the intoxicated state. However, a rationale for this decision to wait for the CT scan was not documented in the patient record.

With respect to MR #1, serious deviations from standards of care were identified as follows:

- -This patient had an incomplete medical assessment which resulted in a significant delay in the diagnosis and treatment of intracranial hemorrhage. CT diagnostic testing for a head injury was not ordered for more than five hours following the patient's arrival to the ED for acute alcohol intoxication and head trauma. This finding contributed to further delay in emergency transfer of this patient to another hospital for neurosurgical intervention.

---This incomplete evaluation resulted in the lack of prompt diagnostic interventions, which further delayed identification and treatment of a subdural hemorrhage. The presence of a head abrasion, highly elevated blood alcohol concentration, decreased Deep tendon reflexes, and evidence of compromised neurological status on Glascow coma scale exam, along with a given history of fall, had warranted immediate CT testing of the head.

-The medical assessment did not address apparent inconsistencies in the events surrounding the patient's alleged fall prior to arrival. The ambulance report noted that the patient was found unresponsive in front of a bar and that he may have fallen. A head abrasion was present. This was at variance with the verbal report provided to the MD by EMS that the patient fell off a stool. However, the inconsistency in the mode/location of injury was not addressed in the work-up of the head trauma.
This discrepancy in history warranted a closer assessment for trauma and need for immediate Head CT to rule out traumatic head injury. The MD based his assessment on the verbal report received from ambulance staff and did not see the PCR document, which usually arrives later.

--There was no assessment if the mechanism of injury was plausible with the inconsistent verbal and written reports from EMS. Medical staff did not address the finding noted on head CT that suggested a fracture of the orbit or maxilla. The staff did not assess if these results were consistent for the mechanism of head injury due to inconsistent reports provided about the circumstances of injury prior to arrival (i.e., the lack of congruence between written report that the patient was found outside the bar versus the verbal report that he had fallen off a bar stool).

--The MD and RN interviewed acknowledged the written ambulance patient care report was not reviewed or received at the time of treatment. It was stated the ambulance call report was reportedly submitted several hours after arrival. At interviews with staff #s 3 and 5, it was reported there were frequent problems with failure to receive timely written ambulance reports in the ED.

-Delay in assessment resulted in the failure to diagnose intracranial hemorrhage and delay in treatment for this head injury patient. The physician did not order medication due to the patient's intoxicated state and reported on interview that CT testing would have required medicating the patient, who was too uncooperative at that time. The rationale for decision to defer testing was not recorded in the medical assessment.

- The physician acknowledged a cerebellar exam could not be performed. The physician's record was also missing documentation of salient observations of the patient's combative behavior.

-There was no evidence documented for immediate neurosurgical consultation. The hospital failed to implement its procedures for requesting specialty consultants and neurological checks.
Review of the facility's written procedures for consultations as described in the Rules and Regulations of the Medical staff booklet revealed the consultation process was ineffective. These procedures do not require timely in person evaluations for up to 12 hours following notification for urgent consults. Procedures indicate that urgent consultation requests may be answered by the consultant MD by phone within 20 minutes and require that evaluations are performed within 12 hours following the notification of request for consult. The process does not define time parameters for on site emergent consults other than these "be answered within minutes by phone" and require arrival to bedside "as soon as possible". In the case of MR #1, the medical staff failed to implement policy to request a neurological consult despite an evident need, secondary to neurological changes observed with reductions in GCS score and deep tendon reflexes.

-The hospital did not implement its procedures in effect for patients with possible fall or dementia for head trauma. This procedure recommended full neurological evaluation and CT scan for evidence of moderate head injury and GCS score of 9-13. Given the patient ' s altered mental status, decreased GCS score of 12, and head injury accompanied by intoxication, radiological testing was indicated to assess evidence of symptoms associated with acute head trauma.

-Nursing did not perform a complete triage assessment for head injury and did not review the written ambulance report. The nurse was initially unaware of the bump on the head and amended the triage note to add the information about the head abrasion and knot to the head following notification by the MD later on about the head injury.

-The patient did not receive appropriate monitoring to assess ongoing neurological status despite compromised neurological function, evidenced by a reduced Glasgow coma scale score of 12. While orders noted hourly neurological checks, this order was not timed and no evidence it was implemented. Per the record, only two GCS exams were performed at 2 AM and at 6 AM, after a period of prolonged unresponsiveness, and both demonstrated neurological compromise.

-There was no evidence of any written orders or direction provided to nursing staff for the management of a patient with acute alcohol intoxication and head injury. The physician did not order a minimum level of observation and monitoring for this patient and had stated on interview that only verbal orders were provided to the nurse to keep a close eye on the patient about every half hour or hourly.

- The patient was placed in an unmonitored room used for respiratory isolation which is out of view of the nursing station. Staff interview with the ED Director on 10/5/10 indicated this room (#6) may be used as needed for intoxicated patients. However it was observed during tours of the ED on 10/5/10 that this room is not under direct observation by security personnel, unlike room #s 8, 9, and 10, which are used for psychiatric patients.
Tour of the ED on 10/5/10 and interview with staff determined that subsequently, there was a camera installed in this room (#6) on 3/16/10 which is connected to a video monitor at the nursing station. However, it was confirmed with the hospital that there was no formal procedure for monitoring of this camera and there were no staff training records to demonstrate direction provided to staff for use of this device for ostensible monitoring of patient activity and safety. Existing procedures for neurological assessment and care of patients with AMS, Intoxication, or Trauma do not define safety measures or surveillance for use of this room with patients with altered mentation.

-Documentation in the medical record and reports from staff interviews determined contradiction in information about the patient's level of alertness, mental status, and behavior. The physician's assessment was incomplete and did not reflect assessment of reported belligerent and combative behavior. The physician reported on interview about the patient's belligerent and uncooperative behavior and described the patient as lethargic but arousable. This was discrepant with nursing documentation and interview indicating the patient was unresponsive, asleep, and responsive to pain. Interview with the nurse on 10/6/10 confirmed the patient was sleeping and unresponsive on arrival. The nurse reported this patient remained asleep during periodic visits made by the nurse at 2 AM, 3AM, 4AM and 5:30 AM.

- There is evidence lab testing was delayed and that orders other than ETOH were not implemented timely. Other than ETOH level, the majority of tests were not ordered until the patient had been in the ED for five hours or longer. The physician (staff #3) did not record the time of orders written for the hourly neurological checks, blood ETOH level, or CT scan of the head. It was stated on interview that the nurse transcribes the orders into the computer. Follow-up computer order documentation received from the facility dated 10/15/10 determined the order entry times by nursing for STAT ETOH was 2:03 AM. Remaining tests were entered as orders into the computer by staff between 5:42 AM and 6:41 AM on 6/28/09. This finding denotes the majority of labs other than alcohol were ordered following the patient's prolonged period of unresponsive status. CT of the head was ordered at 5:52 AM, STAT PT, CBC, & basic metabolic profile at 5:53 AM, STAT C-spine at 6:12 AM, PT & PTT at 6:16 AM, STAT Chest at 6:25 AM, and STAT Drug screen & UA at 6:41 AM.

-Additionally, untimed documentation of medical interventions following intubation of the patient was recorded by a different physician (staff # 1) on the same T form medical document that had already been signed off and authenticated by the physician from the prior shift (staff#3).

-There was no evidence the hospital successfully notified the patient ' s family of his condition and transfer plan. There was no evidence of follow up efforts to contact next of kin following transfer.

II. The following medical records demonstrated incomplete or delayed medical screening examinations for patients presenting for emergency care. Medical screening exams did not consistently reflect interventions or plans to address the patients' presenting problems.
Refer below to MR #s 2 -10.

MR# 2:
Staff did not provide a complete medical screening assessment or proper monitoring for a patient (MR #2) who presented to the emergency room with acute alcohol intoxication on 8/14/09. The patient walked out of the ER after about 10 hours and several minutes later was found to have collapsed outside at the ambulance entrance. The patient was immediately brought back into the ER and despite efforts to resuscitate, the patient expired on 8/15/09.
This 65 year old male was found by EMS on the ground in apparent intoxication with no signs of trauma. The patient arrived to the facility at 6:09 PM and was triaged at 6:15 PM with a chief complaint recorded that he was found in the street and smelling of ETOH. The nurse checked no evidence of trauma. The patient verbalized he had no pain. No triage category was recorded. The medical assessment was recorded at 6:30 PM but was incomplete. The MD could not determine mental status due to intoxication and could not evaluate orientation due to uncooperativeness. Physical examination was partial with no evidence of breathing problems or trauma. However, procedures, laboratory/diagnostic testing, plan of care, and progress sections of this assessment were blank. A fingerstick was ordered (value=130 mg) but no time was noted for this order. No drug toxicology or blood alcohol level was ordered despite the disoriented state. There was no evidence of any medical follow up reassessment for the patient's intoxication or incomplete medical screening.

The patient was monitored only by nursing who noted at 7 PM and 12 AM on 8/15/09 that he was asleep. Only one set of vital signs were recorded. At 4 AM on 8/15/09 the nurse wrote he woke up and walked out of the ED. Discharge instructions recorded that patient was advised about detox. These instructions were signed only by the provider yet there was no evidence of formal discharge documented nor any reassessment of the patient's intoxication status.

At 4:55 AM on 8/15/09, a separate ED encounter record noted the patient was found unresponsive outside of the ER in the parking lot in front of the ambulance entrance. The patient had a laceration and bump on the forehead and was pulseless. He was brought back into the ER and CPR was started which was unsuccessful. The patient expired at 5:26 AM and the results of the ME report noted the cause of death was bilateral pulmonary embolism. The MD noted the patient had been seen 20 minutes earlier by a CNA who had walked him out. The hospital review dated 9/16/09 determined the standard of care was met and the patient had been discharged. However there was no evidence the patient had been medically reassessed or discharged during the first ER encounter where it was noted he had walked out. Refer to MR # 2.

Interview with the Medical Director on 10/7/10 and ED Director on 10/8/10 at approximately 3 PM revealed that testing for alcohol (ETOH) or illicit drugs is not performed routinely for patients treated in the ED for apparent intoxication. The practice is that if the patient is alert, able to speak, and advises the provider of drugs or alcohol used, there is no value in testing for the presence of these substances. Review of facility procedures for blood alcohol concentrations was not updated since 1/97 and indicates this test is "selectively ordered only when knowledge of the alcohol level will affect treatment or disposition of the patient." The facility's current policy dated 6/16/10, entitled " Medical evaluation of patient with a history of possible trauma and with altered mental status or dementia, or intoxication from substance abuse", focuses on the appropriate work up and neurological assessment of the patient, but is silent regarding specific instructions for toxicology screens.

MR #3:
The hospital did not provide complete medical assessment for a patient who was brought in by ambulance on 11/8/09 after having been found lying in the street with bottles of beer. The patient was triaged at 4:10 AM and noted to smell of alcohol ; a red mark to the back of the head was noted. The patient was sleepy but arousable. The patient was medically assessed at 6 AM and noted to have head trauma and head contusion. The patient was sleepy but arousable. Orientation could not be determined. The patient vomited at 6 :15 AM and Zofran IM was given. A head CT was ordered and on the preliminary reading, while a lot of movement was noted, it appeared normal. The patient was discharged at 9:07 am per the discharge instructions but a second official CT was read at 9:45 AM, which revealed a subarachnoid hemorrhage. At 10 AM the Police were contacted to locate the patient but there was no address on the record. The hospital did not completely identify the patient at registration. Information about address and age was incomplete and inaccurate. A stamp on the record indicated the patient's age as "0 d". The chart did not indicate a reassessment of the patient's intoxication- A 6AM physician's note indicated the patient was sleeping but arousable. The RN noted the patient was ambulatory and discharged home with instructions.
Interview with the ED Director on 10/8/10 at approximately 3 PM revealed the first CT was read by the ED attending MD and despite efforts made, the patient could not be located.
The patient did not receive a complete assessment as the patient was discharged prior to the official CT reading of the head which noted subarachnoid hemorrhage.
Refer to MR # 3.

Review of MRs #4 and #5 determined these patients received inadequate medical screening, with specific reference to the lack of direct face to face assessment by a qualified medical provider for application of physical restraints.

MR# 4:
This patient did not receive complete medical assessment or proper monitoring of restraints. This 31 year old male was brought to the ED on 5/4/10 by Police. The chief complaint reported was "Drug abuse - PCP?" Patient was triaged at 9:20 AM and noted to be angry and hostile. Tachycardia noted at 9:25 AM. At 9:30 AM the patient was awake and oriented x 2 and in distress- GCS score=15. He was placed on security watch for safety. Abrasion to the left forehead was noted. At 9:35 AM nursing noted 4 point restraints were initiated secondary to the patient being uncooperative and combative.

At 9:30 AM he was placed in 4 point restraints. Orders noted restraints for 3 hour period from 9:30 AM to 12:30 PM. Justification was noted that Police Department brought him in for probable PCP and he was fighting with Yonkers Police Department and was "not making sense" The orders noted the MD was called but there is no evidence the MD signed the orders or had conducted a face to face patient assessment. There was no explanation for why the order exceeded the 2 hour limit for restraints for patients 18 years and over. There was no restraint nursing monitoring record evident to monitor circulation, range of motion, periodic release, and toileting . The patient was released from restraints at 12:30 PM. and noted to be calm and cooperative.

MD assessment was recorded at 9:40 AM and noted the patient was in an argument with a co-worker. Physical exam was noted but did not contain assessment for the use of restraints. Urine tox was ordered at 10:20 AM. Labs at 10:51 AM noted positive for PCP and cannaboids. CT of the head was negative. The patient was given bactrim and Tylenol; UTI was noted for WBC and RBC in urine.
Nursing noted the patient was discharged at 1 PM, was alert and oriented x 3, and in no acute distress. However, medical documentation checked the patient was medically cleared for a psychiatric consultation. The patient was discharged by the physician at 2:20 PM but did not document the rationale for not requesting a psychiatric consult to assess the patient's assaultive behavior in order to rule out a potential risk for danger to self or others.

MR #5:
This patient did not receive a complete assessment for evident psychiatric needs. This 29 year old male was brought in by ambulance on 6/17/10 following a suicide attempt and complaint of psychiatric disorder. The patient was restrained by EMS due to presenting a danger to others and also brought in by Police. The patient was triaged as a John Doe at 7 PM with a chief complaint of "PCP ? OD" The patient walked in front of a bus. The patient arrived and was agitated and spitting. It was noted the patient was "cuffed" but no evidence of trauma. The patient received emergency administration of haldol , ativan and benadryl at 7 PM as well as an order for emergency application of 4 point restraints. While there was evidence of physician documentation at 7 PM, there was no supporting documentation for the approval of these restraint orders. There was no evidence the MD signed the orders or approved the physical restraints. The restraint order form limited restraint duration for up to 2 hours for persons aged 18 and over. The restraints were initiated at 7 PM but remained on the patient until 12 AM without evidence of an order or face to face physician assessment. The patient was receiving 1:1 watch at 2 AM. The patient was reassessed at 6 am on 6/18/10 by the MD , and noted as awake and alert . The toxicology was positive for phencyclidin (PCP). The patient was discharged but refused to sign discharge instructions which listed referrals for substance abuse program and mental health clinics. The patient was discharged with no psychiatric clearance and without evidence the psychiatric needs were assessed to rule out danger to self or others.

MR #6:
The record for this intoxicated patient revealed triage misclassification and a delay in medical assessment . Medical orders were not present in the record. A male of approximately 20 years of age who was apparently intoxicated was brought in to the ED initially as an unidentified patient by EMS after having been assaulted. The patient smelled of ETOH and noted to have facial abrasions and swelling to right rear of the head. The patient was accepted at the ER at 12:44 AM on 9/30/10 and triaged as urgent for assault with bruises noted to the head and alcohol intoxication. The triage time was illegible but the registration time noted was 12:52 AM. Glasgow coma scale was noted as 13. Hourly neuro checks were initiated and CT of the head was performed at 2 AM. There was a delay in medical screening assessment as the MD documented on the record at 4:20 AM that "by the time I saw the p

Based on record review it was determined that the facility did not effectively ensure that all individual with an emergency medical condition was effectively made aware of the need for further medical examination and treatment as required to stabilize the medical condition.

Findings include:
Review of MR # 11 noted that the patient was brought to the ED by EMS on 8/10/10.
It was noted that the patient ' s chief complaint was shortness of breath (SOB) with medical history of chronic obstructive pulmonary disease (COPD), congestive heart failure ( CHF) & coronary artery disease (CAD). It was noted that the plan was to admit this patient but the patient signed out against medical advice (AMA). The discharge form hospital against medical advice form was reviewed. It was noted that on the form the patient checked " I am leaving " . However, there was no documentation on this form or in the medical record that the patient was informed of the dangers to the patient ' s health of leaving the hospital against medical advice.

Review of MR # 12 revealed inconsistency recorded of the circumstances of patient departure and lack of assessment to determine whether the patient had been stabilized or possessed sufficient mental capability to leave safely. This 45 year old patient arrived by car to the ED on 9/9/10 with complaint of sudden onset of dizziness. The patient was triaged at 3:45 PM as urgent ; vital signs were taken. At 3:50 PM the nurse records the patient suddenly jumped out of the stretcher and left. The patient was noted as loud and profane. There was no medical screening exam on the record. The nurse circled the patient left against medical advice ( AMA) yet there was no indication the patient was advised of the risks or benefits or documentation of any assessment of his capability to leave safely. Additionally there was no evidence of a consent to leave AMA which advises of risks of departure. The ED log for that date reflected the patient had walked out.

Based on review of medical records and procedures, it was determined that the facility did not ensure that transfer requirements were met which require informed consent or transmission of medical record copies to the receiving facility. These deficiencies were identified in 6 of 23 applicable records for patients who were transferred to other facilities. Refer to MR #s 1, 13, 14, 15, 16, 17.

Findings include:
Review of six records on all dates of the survey for patients transferred to other facilities for medical or psychiatric reasons determined these were missing transfer consents signed by the patient or designee or did not demonstrate confirmation that complete record copies were sent to receiving facilities for continuity of care.
Examples:

MR #1: This patient was transferred to another facility for neurosurgical intervention on 6/28/09 but the record lacked evidence of documented follow up with the next of kin to provide proper notification of transfer. See specific citations noted under tag # A2406.

MR # 13: This 17 year old was evaluated in the ED for suicidal ideation and transferred to a psychiatric hospital on 9/28/10. While there is evidence of written consent from the patient's mother, the "acute care inter-facility transfer checklist" form that was implemented by the facility during June of 2010 was incomplete. The form did not document whether copies of the medical record was sent with the patient. There was no supporting documentation available in medical or nursing progress note to indicate the copy was sent. Interview with the facility administrator on 10/5/10 revealed that copies are always sent with transferred patients and the expectation is that the transfer checklist form must be completed.

MR #14: This 33 year old male was seen in the ED for depression and transferred to a psychiatric facility on 9/18/10. While the patient was certified for involuntary admission status due to potential for self harm, the patient was assessed to be alert/oriented x 3 and coherent . There is no evidence the patient was advised of transfer or that the surrogate was consulted for consent. The authorization for transfer form did not document a rationale for lack of consent to transfer.

MR#15: This 48 year old male presented with chest pain on 9/9/10 and was transferred to another hospital for catheter lab. The record lacked evidence of patient consent or documentation that the copy of the record was sent. Nursing documentation noted the patient's sister was notified but it was unclear why consent was not obtained from the patient, who was noted as alert, oriented x 3. The acute care inter-facility transfer checklist was incomplete.

MR #16: This 13 year old child was seen in the ED on 9/27/10 for threatening to kill his stepfather and sister with a knife. The patient was transferred to a psychiatric hospital. The acute care inter-facility transfer checklist was incomplete and did not demonstrate evidence that a copy of the record was sent to the receiving facility.

MR #17: This 10 year old male was evaluated for appendicitis and transferred on 9/11/10. There is no documentation that that the medical record copy was sent to the receiving facility on the acute care inter-facility transfer checklist.