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Based on observation, review of signage and interview, it was evident that the emergency department posted a sign that had the potential for discouraging certain persons from accessing emergency services.


Findings include:

During the tour of the ED on 8/8/11 at approximately 10:30 AM, a sign was noted on the quick registration desk in the waiting room of the ED. The sign displayed a New York State Driver License and stated in bold white letters "We request government issued photo identification at time of registration." At the bottom of the sign, in smaller black letters it stated that "Treatment will not be denied, delayed or postponed for missing identification."

The sign that has a driver's license on it and asks for government ID for registration/ triage in bold letters with a disclaimer in small letters represents a potential for discouraging undocumented persons, persons who have suspended drivers licenses, and those with other legal issues from registering as patients.

At the time of observation of the triage area on 8/8/11 at 10:30 AM, walk-in patients seeking emergency care were asked to complete a pre-triage form, titled, "Emergency Room Quick Registration", in which this form documents at the bottom of the form," Please have a form of ID for Registration" written in English and Spanish.

At interview with the Patient Finance Advisor (PFA) on 8/8/11, it was confirmed that he asks for identification at the time walk -in patient are quick registered for triage. At interview with Nursing Administrative staff on 8/8/11, it was stated that this request is for patient identity verification purposes only and would prevent identity impersonation.
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Based on review of the emergency department 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:

1. Review of the emergency department log, titled "ED Record Reconciliation" on 8/8/11 found the facility did not distinguish between patients who left prior to triage versus patients who left before physician (MD) evaluation.

Specific reference is made to two medical records , MR #3 and MR # 4 , for which the emergency logs noted the patients had left before a physician evaluation when in fact neither record had evidence of a triage assessment.

Review of Medical Record #3 on 8/8/11 found it contained a nursing note on 4/20/11 that recorded, " patient was to be placed in isolation due to suspected chicken pox, but patient refused for now and walked out before MD evaluation.". There was no record of any nursing triage.

The emergency log was incorrect in that it noted the patient walked out before the MD evaluation but did not specify that the patient had actually walked out before nursing triage.

Review of MR #4 on 8/8/11 found that this patient presented to the ED on 5/25/11 at 1453 with a panic attack. The patient said she was leaving at 1546 (3:46 PM). The record was missing documentation of nursing triage. However the ED log actually noted the patient left before MD evaluation and hence did not differentiate the patient had left prior to triage.

2. In the instance of MR # 5, the ED log dated 6/9/11 had inaccurately noted the patient walked out before MD evaluation, yet review of the medical record revealed the patient had been admitted to the hospital.
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Based on staff interviews and review of records and policy/procedure, it was evident that the facility did not perform a medical screening examination for patients in a timely manner.

Findings include:

1) Review of MR#1 found that the patient was triaged but never seen by the ED physician (Emergency Department). The patient presented to triage with a complaint of headache and episode of epistaxis and was assigned a triage category of ESI 3 but was never seen by the physician. There was a reference to a recent history of a cardiac catheterization in the triage note and the medications used by the patient as self reported include Plavix and Lovaza.

There was no note as to whether the patient was questioned as to the reason for and the results of the cardiac catheterization. There was no evidence that nursing staff made a clinical correlation between the nosebleed and the potential side effects of Plavix.

The patient in MR#1 presented to the ED Patient Financial Advisor (PFA) and completed the form at 12:36 PM, and was triaged at 12:53 PM complaining of headache and an episode of epistaxis since the night before and was assigned a triage category of ESI 3, which is a moderately urgent category.

At 1453 (2:53 PM ) there was the original vital signs recopied and a focused assessment for nosebleeding. At 1709 hours ( 5:09 PM) there was a re-assessment by the ED technician which consisted on only a vital signs measurement. The patient left the ED at an unknown time and in an unknown manner.

There was no re-assessment by Registered Nurse after 2:53 PM and the re-assessment at 5:09 PM was not focused on the complaint but consisted of a set of vital signs only.

Thr facility has an ED policy and procedure ( ED 1200 ) that stipulates that patients who are given triage category ESI 3, 4, and 5 are to be re-assessed every 4 hours. It states that the re-assessment is to include a full set of vital signs. There is no reference as to what nursing staff may perform this task and what other assessments are to be made other than vital signs.

At interview with the Vice president of Patient Care Services on 8/8/11, it was stated that charting is done " by exclusion " which would not require documentation if there was no relevant change in the patient's condition.

2) Based on review of medical record, it was determined the hospital failed to provide timely medical screening of a patient with abnormally elevated blood sugar.
Findings include:
Review of MR #2 on 8/8/11 found this 51 year old insulin dependent diabetic who arrived complaining of tingling of the hands and no access to insulin for one week. The patient specifically was asking for assistance in obtaining insulin. The patient was triaged as ESI 3 on 12:32 PM on 3/22/11. The patient's non-fasting Fingerstick was 391.

There was no evidence that a medical screening examination was performed nor did the patient receive any insulin. There was no evidence of social service referral or intervention to assist the patient in obtaining medically necessary medication. A nursing note at 8:44 PM entered by a nurse stated the patient was not in the ER at 7 pm.


3) Based on review of medical record, it was determined the hospital failed to provide timely triage and medical screening of a patient who was suspected to have chicken pox.

Findings include:

Review of Medical Record #3 on 8/8/11 found that the electronic medical records consisted solely of a nursing notation on 4/20/11 that this patient was to be placed in isolation due to suspected chicken pox. The notation documented that the patient refused and walked out before the MD evaluation. The patient was advised to call his physician for follow up.

The record lacked a triage assessment and hence lacked an objective basis for the suspected chicken pox and need for isolation.

Additionally, the emergency log was incorrect in that it noted the patient walked out before the MD evaluation but did not specify that the patient had actually walked out before triage.
On 8/8/11, the hospital staff was unable to locate the patient' s initial triage registration form titled , "Emergency Room Quick registration " form. This form is normally completed by all patients who walk in to the emergency department who seek care.

Follow-up documentation provided by the hospital on 8/10/11 confirmed there was no evidence of triage assessment documented and and no evidence the hospital was able to retrieve the quick registration form, which is completed by the patient at the time of arrival. EAGLE computer documentation submitted indicated the triage level was noted as 3 for "unknown" nature of illness.

There was no record that any ED staff took the patient to the isolation room for triage and no assessment for how long a patient with a potential contagious condition was allowed to remain in the waiting room.

4) Based on observation and interview, the hospital did not submit evidence that they ensured emergency access to services from a main entrance to the emergency department.

Findings include:

During the facility tour on 8/8/11 at approximately 9:30 AM, it was found that a main entrance to the ED and the hospital is located at the top of a hill which is approximately 25 feet above the main road where there are no steps to walk up. There is a steep inclined winding walkway that resembles a ramp-driveway. At the foot of the driveway, there is a security guard station that is not always manned.

At 9:30 AM, there was no clear signage that gives direction to patients who may have difficulty walking up the hill to access emergency care. A sign is posted with a wheelchair inscribed with no specific directive as to how to notify the staff that assistance may be needed at the foot of the ramp. The words inscribed on this sign notes, " Access at loading dock". There is no direction to press a "buzzer" noted at the foot of the ramp. There was no indication as to what the buzzer is for.

During interview with the Director of Patient Services Administration on 8/8/11, it was stated that there is a sign posted at the access ramp. After the conclusion of the survey, the survey team exited the facility at 5:50 PM on 8/8/11 and noticed a sign was posted that instructed persons on how to obtain assistance which had not been present during the earlier tour conducted by the surveyors.
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27378

Based on staff interview and records reviews, it was evident the hospital did not develop a formalized written policy that addresses the on-site psychiatric stabilization of ambulatory patients who present to the emergency room with immediate mental health needs.

Specific reference is made to the lack of written policy that reflects hospital practice that involves the immediate transport of persons who present with psychiatric emergencies to the psychiatric emergency room at the main campus hospital located approximately three miles from the facility for the purpose of initial psychiatric assessment and stabilization.

Findings include:

Interview of staff and record review on 8/8/11 found the hospital has not engaged in a safe practice for psychiatric emergency care in that they have not formalized a procedure that arranges the provision of timely or immediate on-site initial psychiatric assessment of ambulatory patients who present to the emergency department for assessment and treatment of emergency mental health needs.

Despite the hospital having an inpatient psychiatric unit, the emergency department does not have a dedicated comprehensive psychiatric emergency department. No direct inpatient psychiatric admissions occur from the emergency room. The hospital has instead engaged in a practice to transfer all patients who require emergency psychiatric assessments or admission to another emergency room located at its main campus hospital by ambulance despite having a unit located within the hospital where psychiatric inpatient services are offered. This practice does not ensure initial psychiatric care is provided in a manner that minimizes potential delays in psychiatric screening and care.

It was stated at interview with the ED Medical director on 8/8/11 that the inpatient psychiatrist covers only inpatients and that the hospital does not staff its ED with psychiatrists for assessments of psychiatric emergencies. Patients with mental health needs presenting to the emergency room are first cleared medically and placed on 1:1 supervision as necessary. Ambulance arrangements are then made to transport these patients to the emergency room at its main campus, which is located more than three miles away. Prior to transfer or transport to the main campus , the facility's ED staff does not provide initial psychiatric consultation or psychiatric treatment and stabilization before transfer.

This practice that requires all patients with psychiatric emergencies be transported to an alternate hospital emergency room location for the purpose of initial psychiatric assessment and stabilization has not been formalized into written emergency hospital procedures.

It was also stated by administrative staff on 8/8/11 that no patients can be admitted to the psychiatric unit located within this hospital unless first assessed by psychiatric emergency staff at the emergency room located at the main campus approximately 3.5 miles away, where formal psychiatric assessments are provided before admission is possible to the hospital's own inpatient unit for psychiatric care.

At interview with administrative staff on 8/8/11 at approximately 2 PM, it was determined that despite having a 30 bed inpatient psychiatric unit in the hospital, the hospital does not provide psychiatric staff to cover the ED or provide on-site assessments of patients presenting with mental health emergencies.

It was stated patients transported by ambulances are taken to the main campus hospital emergency department, since ambulance providers know that the emergency room does not provide initial psychiatric care.

The lack of written policy and procedure to ensure timely psychiatric assessment and failure to develop safe transport procedures creates a potential risk for the safety of psychiatric patients and does not ensure the timely provision of emergency psychiatric screening with minimal delay. Patients do not sign consent for transfer to the main campus , as it was stated that the transport does not constitute a transfer.
At interview with the Corporate Director Patient Services/Regulatory Affairs on 8/8/11 , it was stated in response to a question about safety during transport, that ambulances chosen for transport of psychiatric patients would be selected based on specific patient needs. However, there was no reference to this practice in any policy or procedure that specified patient safety and monitoring during transport. There are up to three ambulance companies in use (two contracted and one hospital-owned) to transport psychiatric patients to the main campus . Selection of ambulance providers is "based on needs." Instructions are not given for one to one monitoring during transport, and it was also stated by Administrative Nursing staff that in instances of danger, the hospital would send additional personnel in the ambulance with staff for safety reasons. However this process is not formalized into policy and there are no guidelines pertaining to patients whose monitoring might include restraints or response to medication during transport.
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27378

1) Based on record review and interview, it was determined that the emergency department did not incorporate the use of a quick registration system into its triage policy.

Findings include:

Review of the triage policy and procedure (#ED 1200 ) on 8/8/11 found that there was no reference to the use of patient financial advisors in the process in the pre-triage process. There was no policy for the Quick Registration Process found in ED policies.

Review of the job description for the Patient Financial Advisors ( PFA ) found no reference to the specific practice of asking the patients for their chief complaints and making an assessment to determine if the patient requires immediate triage. Review of the job description form the PFA's also made reference to screening for medical necessity. At interview with the Hospital Administration on 8/8/11, it was stated that this statement applied to areas outside the ED and no application to the these persons "screening " patients in the ED.

At interview with the PFA on duty on 8/8/11, at approximately 10:30 AM, it was stated that he is the first person who greets walk in patients who arrive for triage and asks them to complete the form for Quick Registration. He does not enter any information into the computer at that time ( the first encounter). The patient will take the form and complete it and then return to the PFA a second time, at which point the PFA asks for identification and enters the data into the computer system for triage (second encounter). It was stated that he would call the triage nurse only if the patient reports a serious matter such as chest pain. This statement represents the activity of triage.