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Based on review of the emergency department (ED) central log, from March 2014 to June 2014 it was determine that the facility failed to provide complete and accurate information.

Findings Include:

Review of the central ED log on 9/17/14 at approximately 11:15 AM, it was noted that patient in MR #8, a 3 year old (y/o), was brought in by his mother to the ED on 6/30/14 at 2:40 PM with a complaint of a cut lip. The ED nurse noted at 3:52 PM that the attending physician assessed the child prior to being triaged. The ED nurse noted that there was no further treatment needed and that the child was alert and in no distress. The ED nurse noted that teaching was done with the mother; and that the mother verbalized that she understood. The facility had recorded this patient disposition as a voluntary walk out. The medical record was requested from the facility. Staff #7 was interviewed on 9/18/14 at about 1:35 PM and stated there was no chart and provided a print out with an attached sticky note. Hand written on the sticky note was "voluntary walk out after arrival but before triage no chart".

Review of the comprehensive psychiatric emergency program (CPEP) ED log on 9/17/14 at approximately 10:05 AM, for the period of March 1, 2014 - June 30, 2014, noted several missing diagnoses and dispositions for the month of June.

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Based on documents reviewed, interviews, review of medical records and hospital's policy, it was determined the facility failed to ensure that each individual who comes to the Emergency Department (ED) receives an appropriate medical screening examination (MSE) to determine if an emergency medical condition exist. Specific reference to three (3) of twenty three (23) patients (MR #1, MR #2, & MR #4) who presented to the facility's ED with a request for medical examination or treatment, but left the facility's dedicated ED without a physicians' evaluations (MR #1 & MR #2) or who left the ED without a complete physician's evaluation (MR #4).

Findings:

Review of the NYC 911 System Provider Patient Call Report for unit 1563 dated 8/29/14 for patient in MR #1 and the PREHOSPITAL CARE REPORT SUMMARY FDNY dated 8/29/14 for patient in MR #2, both documents indicated that the patients were refused at hospital 25 and transported to other facilities.

There is no documentation to indicate that upon ambulance arrival to the CPEP that patients in MR #1 and MR #2 were evaluated and treated. Interviews with staff #2 on 9/18/14 at 12:45 PM, staff #1 on 9/18/14 at 2:25 PM, and staff #3 on 9/19/14 at 12:45 PM indicated that two patients were brought to the CPEP (Comprehensive Psychiatric Emergency Program) via ambulances on 8/29/14 at about 10:00 PM.

The CPEP diversion log for 8/29/14 indicated that the unit was on diversion for pediatric and adult on 8/29/14 from 1607 (4:07 PM) - 2359 (11:59 AM) as per the psychiatrist.

On interviews of staff #1 and # 2 on 9/18/14 at 2:25 PM and 12:45 PM respectively, both stated that they did not know what happened to the patients. However staff #3 stated that the patients were not seen and did not recall how long the patients were there.

The facility staff failed to evaluate and treat patients in MR #1 and MR #2 and to keep a written record of the time that they remained in the ED.

MR #4 was reviewed on 9/18/14. It was noted that the patient, 24 year old, with history of asthma and sickle cell, was seen in the facility's Emergency Department (ED) on 8/23/2014 at 1402 (2:02 PM). The chief complaint was generalized body pain x 4, sickle cell crisis and abscess to the left armpit. The patient was placed in triage class: 3. It was noted that this patient was placed in the wrong Triage Classification. As per hospital's triage policy, patients with sickle cell crisis will be placed in triage level 2.

It was noted that there were physician's orders for: Morphine Sulfate 4 milligram (mg) IVP (Intravenous Push) on 8/23/2014 at 1722 ( 5:22 PM), Dilaudid 2 mg IVP on 8/23/2014 at 1801 (6:01 PM) and Benadryl 25 mg capsule (cap) orally on 8/23/2014 at 1801 (6:01 PM). It was noted that the above medications were discontinued on 8/23/2014 at 1822 (6:22 PM). There was no evidence that these medications were administered. On 8/23/2014 at 2106 (9:06 PM) , the nurse noted "no IV access obtained while in ED". There was no documentation on the reason why the IV (intravenous) access was not obtained. There was no documentation why the orders were discontinued.

It was noted that there were new physician's orders for Dilaudid 2 mg subcutan (subcutaneous) on 8/23/2014 at 1822 (6:22 PM) and Benadryl 25 mg IM (Intramuscular) on 8/23/2014 at 1822 (6:22 PM). It was noted that Benadryl and Dilaudid were administered on 8/23/2014 at 1825 (6:25 PM). This patient presented in the ED with sickle cell crisis on 8/23/2014 at 1402 (2:02 PM), but this patient was not provided with any intervention until 1825 (6:25 PM), over four hours later.

On 8/23/2014 at 2052 (8:52 PM), the record indicated that the patient's diagnosis was sickle-cell disease with crisis and the disposition: walked out during evaluation (eloped). It was noted that the patient walked out of the ED, six hours after presenting in the ED, without a medical screening examination. It was noted that in spite of the nature of the patient's presented complaints, this patient did not have IV fluid, blood work, or a physical examination. The reason why these interventions were not done was not documented.

Staff #5 was interviewed on 9/18/2014. This staff reported that the patient was seen by the chief resident who addressed the patient's presented complaints. According to Staff #5, once the patient is assigned to the primary physician, that physician would do a complete evaluation and write the progress note. He also stated that, at the time the patient left the hospital, the patient was not assigned to a primary physician.