HospitalInspections.org

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Based on document review, video review, interview, and one (1) of thirty-one (31) Medical Records reviewed, the facility failed to provide an appropriate Medical Screening Examination.

The lack of a Medical Screening Examination may have placed patients at increased safety risk if an emergent medical condition existed.

Findings:

Review of Electronic Registration Encounters revealed that Patient #4 had a Registered Visit to the Pediatric ED on 09/14/17 from 12:22PM to 12:56PM.

Review of the facility's security video of the Pediatric Waiting Area, dated 09/14/17 from 9:00AM to 6:00PM, identified Patient #4, carried in the arms of a woman accompanied by a second woman, entering the Pediatric Waiting Area on 09/14/17 at 12:16PM. From 12:16PM to 12:17PM, the second woman signed in to the Reception Desk manned by Security Staff. They were called into the Triage Room by Staff P (Registered Nurse) at 12:21PM, exited the Triage Room at 12:32PM and exited the facility at 12:33PM. Total time in the Triage Room was eleven (11) minutes and the total Pediatric ED visit encounter lasted seventeen (17) minutes.

Review of the facility's security video of the Pediatric ED Treatment / Triage Hallway, dated 09/14/17 from 12:00PM to 1:00PM, identified that Staff P (Registered Nurse) entered the Triage Room at 12:19:53. At 12:24:50, Staff P exited the Triage Room, walked to the Pediatric ED Nursing Station, out of camera view, then along with Staff Q (Registered Nurse), re-entered the Triage Room at 12:26:48. Staff Q exited the Triage Room at 12:32:57. These observations were confirmed with Staff J (Director) and K (Coordinator) on 10/10/17 at 12:45PM, who identified the staff members and confirmed that Patient #4 did not leave the Triage Room to enter the Treatment Area.

During an interview with Staff Members P and Q on 10/11/17 at 11:30AM, both confirmed having an encounter with the two (2) women and Patient #4 in the Pediatric Triage Room. Staff P stated that during Registration, the two (2) women presented discharge information from another facility indicating that Patient #4 required follow-up appointments with Orthopedics and Cardiology. Staff P stated that she was not certain the women were in the correct location, so she showed the discharge information to Staff Q. Staff Q reviewed the paperwork, asked the women if Patient #4 needed emergency care and they replied no.

Staff Members P and Q then spoke with the Attending Physician on duty, presented the Discharge Paperwork to the Attending Physician for review, and were instructed to direct the women and Patient #4 to the Orthopedics and Cardiology Outpatient Clinics. Staff Members P and Q stated they provided the women with directions and the telephone number for Pediatric Services.

When asked if they or the Attending Physician physically examined Patient #4, Staff P stated, "No, the baby looked fine, there wasn't any distress." When asked why a Triage Assessment, Vital Signs or a Physical Examination were not performed on Patient #4, Staff Q stated, "The paperwork said they needed to follow-up. We asked [the women] several times if they needed emergency care and they said no." When asked if they documented any information or assessments into the Medical Record, Staff Members P and Q both replied, "no". This was confirmed with Staff V (Administrator).

Review of Patient #4's Medical Record identified this three (3) day old infant arrived to the Pediatric ED on 09/14/17 at 12:22PM and was discharged on 09/14/17 at 12:56PM. No Triage Nursing Assessment or Nursing Documentation was found. No Medical Screening Examination was found. No documentation was found indicating any type of Nursing or Physician Screening or Physical Assessment had been performed. No Discharge information was found. This was confirmed with Staff V (Administrator).

The facility's Policy and Procedure titled "Triage" dated 11/22/16, stated the following: "Triage collects all pertinent medical information necessary to make a decision concerning immediacy of medical attention (this includes chief complaint, past medical history, current medications, vital signs) ...All patients presenting to the ED [Emergency Department] will undergo the process of Triage and have a triage priority documented ... Triage information and priority level will be documented on the Medical Record ..."

The facility's Policy and Procedure titled "Patient Assessment and Care" dated 10/01/13 stated the following: "Patients presenting to the ED will be evaluated by the ED staff under the supervision of the attending physician. The ED attending physician will be responsible for determining the appropriate treatment and disposition of the patient ..."

Review of the facility's Registration Encounters identified that Patient #4 visited the Outpatient Pediatric Clinic in Commack on 09/18/17. Review of Patient #4's Medical Record from the Pediatric Clinic identified a Discharge Summary from the facility where Patient #4 was delivered, dated 09/13/17. The Summary stated, "Your baby's dislocated hip needs immediate treatment begun ... I strongly urge you not to delay your return to [place of residence] as it should be started soon. If you do still proceed to New York City you should call a children's hospital and make arrangements for a Pediatric Orthopedist to see her and get her fitted for a harness ... Keep plans for the visit with a Pediatric Cardiologist for follow-up of the Pericardial Effusion that was seen on prenatal ultrasound."