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Based on document review, interview, and observation, it was determined that the Governing Body failed to demonstrate it is effective in carrying out the responsibilities for the operation and management of the hospital. The Governing Body failed to provide necessary oversight and leadership as evidenced by the lack of compliance with the following Condition of Participation:

42 CFR 482.55 - Emergency Services.

Based on medical record review, staff interviews, and review of facility policies and procedures it was determined that the facility failed to meet the emergency needs of patients in accordance with acceptable standards of practice.

Findings include:

1. The facility failed to implement its policies and procedures, and failed to ensure all policies and procedures are commensurate with New Jersey state laws. (Cross refer Tag 1104).

A. Based on review of facility policies and procedures, and staff interview, it was determined that the facility failed to ensure implementation of its policy for Triage of Obstetrical (OB) patients coming to the Emergency Department (ED).

Findings include:

Reference: Facility policy and procedure titled, 'Triage' Special Triage Circumstances,' B. OB Patients states, "All pregnant patients are to be triaged by the triage /charge nurse upon arrival into the ED."

Staff #12 stated during interview on March 20, 2014, that when a pregnant patient arrives at the ED she is sent directly to the Labor Triage Room if she is 16 weeks or greater gestation. The Patient is not evaluated and triaged by the ED nurse in the ED, as per policy.


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B. Based on medical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure the restraint policy was implemented.

Findings include:

Reference: Facility Policy Guideline: The Use of Restraint and Seclusion, page 3 of 8, states "... Role of RN ... 6. RN documentation includes: "... b. Less restrictive measures attempted. ... f. Oversees that flow sheet is being filled out correctly and signing accordingly..."

1. Documentation in Medical Record #38 indicated Patient #38 was placed in restraints on 2/15/13 at 12:50 PM, and released from restraints at 3:45 PM.

a. There was no documentation in the medical record of less restrictive measures being attempted.

b. The Restraint Flow Sheet for hourly checks by the RN for 2:00 PM and 3:00 PM was not completed or signed accordingly. There was no evidence of an RN's initial in the boxes provided on the form to indicate an hourly visual check of the patient, or a 2 hour assessment of the patient's skin integrity, range of motion, toileting needs, nutrition or fluid offering, turning and positioning, circulation, and continued need for restraint.

c. The Restraint Flow Sheet for the 15 minute checks by the patient care technician for 1:30 PM, 1:45 PM, 2:00 PM, 2:15 PM, 2:30 PM, and 2:45 PM was not completed or signed accordingly. There were no initials, in the boxes provided on the form, to indicate the patient was observed at these 15 minute intervals.

2. Documentation in Medical Record #39 indicated the patient was placed in restraints on 2/16/14 at 7:05 AM and released from restraints at 11:31 AM.

a. There was no documentation in the medical record of less restrictive measures being attempted.

b. The Restraint Flow Sheet for hourly checks by the RN for 11:00 AM was not completed or signed accordingly. There was no evidence of an RN's initial in the boxes provided on the form to indicate an hourly visual check of the patient.

c. The Restraint Flow Sheet for the 15 minute checks by the patient care technician for 11:00 AM, 11:15 AM, and 11:30 AM was not completed or signed accordingly. There were no initials, in the boxes provided on the form, to indicate the patient was observed at these 15 minute intervals.

3. The above was confirmed by Staff #1.

4. On 3/24/14 review of the facility's QA for the ED lacked evidence of QA activities for the year 2013. Staff #2 confirmed there was no QA of restraints in the ED for 2013.


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C. Based on medical record review, staff interview, and review of facility policy and procedure it was determined that the facility failed to implement its policy and procedure for triage of all patients coming to the emergency department (ED).

Reference: Facility policy and procedure titled 'Triage' states "Policy: All patients presenting to the ED will be seen by a Registered Nurse who has been deemed competent in the triage process and be assigned an appropriate acuity level. Triage is the continuous process of assessment and prioritization that begins at the time of patient presentation into the Emergency Department."

1. Review of Medical Record #3 indicated Patient #3 arrived to the ED on 6/4/13 at 15:18.

a. The Nursing Progress Notes indicated on 6/4/13 at 19:15 that Patient #3 left without being triaged.

2. There was no evidence that the patient was triaged in the 3 hours and 57 minutes from the time of his/her arrival on 6/4/13 at 15:18, until the time it was documented he/she left without being triaged on 6/4/13 at 19:15.

3. Review of the ED log indicated Patient #15 arrived to the facility on 6/2/13 at 01:54 and left without treatment at 05:14. There was no evidence of a provision of a triage assessment to Patient #15 for 3 hours and 20 minutes, from the time of his/her arrival on 6/2/13 at 01:54 until the time he/she LWOT at 05:14.

D. Based on review of facility policy and procedure, medical record review, and staff interview it was determined that the facility failed to have a policy and procedure that guides nursing practice in triage.

Findings include:

Reference: Facility policy and procedure titled 'Triage' lists "Triage Acuities" as Immediate, Emergent, Urgent, Semi-Urgent, and Non-Urgent.

1. On 3/20/14, 34 medical records for ED patients were reviewed. The triage acuities indicated numerical values for triage. There was no indication if the patients had acuity levels of Immediate, Emergent, Urgent, Semi-Urgent, or Non-Urgent, as per facility policy in all 34 medical records.

2. Staff #2 stated in interview on 3/20/14 at 11:50 AM that the lower the score, the worse off the patient is. It was confirmed that Immediate is a Level 1, Emergent is a level 2, Urgent is a level 3, Semi-Urgent is a level 4, and Non-Urgent is a level 5.

E. Based on medical record review, staff interview, and review of facility policy and procedure it was determined that the facility failed to complete triage reassessments on all patients waiting for a medical screening examination (MSE), as per facility policy.

Findings include:

Reference: Facility policy titled 'Triage' states "Procedure: ... --[facility initials]-- Emergency Department triages patients and assigns acuity levels based on the 5 Level Emergency Severity Index Triage Classification System. ... Triage Reassessment The RN must reassess and document that reassessment on all patients waiting for an MD evaluation based on the acuity level assigned at a minimum of:
Immediate Constant and Continuous
Emergent Every 15 minutes
Urgent Every 30 minutes
Semi-Urgent Every 60 minutes
Non-Urgent Every 120 minutes ..."

1. Review of Medical Records #1, and #4, indicated these ED patients were not reassessed according to facility policy, every 30 minutes, while waiting for their medical evaluation:

a. Patient #1 arrived to the ED via ambulance transport on 6/4/13 at 1420, and was triaged upon arrival as an acuity level 3-Urgent. Triage ended at 2:25 PM [14:25].

i. The Nursing Progress Notes indicated that the first call for Patient #1 to be seen was on 6/4/13 at 20:00, 5 hours and 35 minutes after triage ended. There was no evidence of documented 30 minute reassessments of Patient #1 while he/she was waiting for his/her medical evaluation.

b. Patient #4 arrived to the ED on 6/4/13 at 15:27, was triaged at 15:31 as an acuity level of 3-Urgent. Triage ended at 3:36 PM [15:36].

i. The Nursing Progress Notes indicated a repeat Accu Check was completed at 1658, one hour and twenty-two minutes after the completion of triage.

ii. The Nursing Progress Notes indicated the first call for Patient #4 to be seen was at 18:46. This is one hour and 48 minutes after the documented Accu Check reassessment at 1658.

iii. There was no evidence of documented 30 minute reassessments of Patient #4 after the completion of triage, or between the time of his/her repeat Accu Check to the time he/she was first called to be seen.

2. The above findings were reviewed with and confirmed by Staff #2 and Staff #3.

3. Patient #12 arrived to the facility on 6/2/13 at 2:04 AM for complaints of suprapubic pain and nausea, and was triaged at 2:22 PM as an acuity level of 3-Urgent. Triage ended at 2:27 AM.

a. Documentation in the medical record indicated the patient LWOB on 6/2/13 at 06:25.

b. There was no evidence of nursing reassessments every 30 minutes, for the 3 hour and 58 minutes while the patient was waiting for his/her medical evaluation, from the time triage ended at 2:27 AM, until the patient LWOB at 6:25 AM.

4. Review of Medical Record #22 indicated Patient #22 arrived to the facility on 8/19/13 with complaints of chest pain at 1412, and was triaged at 1426 as an acuity level of 3-Urgent. Triage ended at 2:28 PM [1428].

a. The MSE was completed at 2036, 6 hours and 24 minutes after Patient #22's arrival to the ED. There was no evidence of nursing reassessments every 30 minutes while the patient was waiting for his/her medical evaluation.

5. Review of Medical Record #23 indicated Patient #23 arrived to the facility on 7/8/13 at 11:04 AM for complaints of dizziness X 2 weeks, and was triaged at 11:39 AM as an acuity level of 3-Urgent. Triage ended at 11:45 AM.

a. Documentation in the medical record indicated the patient LWOB on 7/8/13 at 19:16.

b. There was no evidence of nursing reassessments every 30 minutes, for the 6 hours and 31 minutes while the patient was waiting for his/her medical evaluation, from the time triage ended at 11:45 AM until the patient LWOB at 19:16.

6. Review of Medical Record #26 indicated Patient #26 arrived to the facility on 7/9/13 at 1717 for complaints of ear pain 10/10, and was triaged at 1725 as an acuity level of 4-Semi-Urgent. Triage ended at 1728.

a. Documentation in the medical record at 1937 indicated that the patient notified the greeter he/she was leaving, and was seen leaving the waiting room.

b. There was no evidence of nursing reassessments every 60 minutes, for the 2 hours and nine minutes while the patient was waiting for his/her medical evaluation, from the time triage ended at 1728, until the patient was seen leaving the ED at 1937.

7. Medical Record #31 was reviewed and indicated Patient #31 arrived to the facility on 9/24/13 at 2139 with complaints of cervical cancer, pregnant, weakness, lightheadedness, and pain 8/10. The patient was triaged at 2139, and per the triage assessment, the patient's family member reported that the patient has had intermittent headaches, that were worse that day with vomiting and hallucinations. The patient was triaged as an acuity level of 2-Emergent. Triage ended at 9:54 PM.

a. Documentation in the medical record indicated Patient #31 was first called to be seen on 9/25/13 at 0015, and there was no answer.

b. There was no evidence of nursing reassessments every 15 minutes, for the 2 hours and 21 minutes while the patient was waiting for his/her medical evaluation, from the time triage ended at on 9/24/13 at 0015, until the time the patient was first called to be seen on 9/25/13 at 0015.

c. The above findings were reviewed with and confirmed by Staff #2 on 3/27/14 at 12:05 PM.

F. Based on staff interview and review of facility policy and procedure it was determined that the facility failed to have a policy and procedure that directs the facility staff in cleaning leather restraints between each patient use.

Findings include:

1. On 3/24/14 at 10:15 AM the ED was toured in the presence of Staff #1 and Staff #2. Staff #18 and Staff #19 were interviewed at 10:30 AM regarding the use of leather restraints in the ED. Staff #18 and Staff #19 indicated the leather restraints are kept in security, are brought out to the ED by security for application to a patient, and then the ED security guards put the restraints back in the box that contains all the leather restraints in the security office.

2. Staff #13 confirmed that the leather restraints are not cleaned between each patient use. Staff #13 stated at 10:30 AM that he/she assigned an officer to clean the leather restraints once a week on Wednesdays.

3. Staff #20 stated in interview that he/she cleans the leather restraints with bleach and hot water. Staff #20 stated the director of infection control showed him/her how to clean the restraints.

4. Per Staff #13, he/she does not have any evidence of training for Staff #20 on the procedure for cleaning the leather restraints.

5. Review of the facility's policy for restraints lacked any guidance as to how to clean the leather restraints.

G. Based on medical record review, staff interview, and review of facility policy and procedure it was determined that the facility failed to implement its policy and procedure for emergency department (ED) dispositions.

Findings include:

Reference: Facility policy and procedure titled 'Emergency Department Dispositions' states "... Purpose: To ensure that all patients presenting to the emergency department who choose not to continue their treatment for any reason with or without notification to the Emergency Department staff are properly disposition. Procedure: Walk Outs: Any patient who receives neither a triage nor a Medical Screening Exam and leaves the ED after "check in" will be considered a walk out. A Triage record will be started with whatever information is available for the tracking board; the patient will be called a minimum of every 15 minutes for three attempts. These attempts will be documented on the triage record. Once it is determined the patient has indeed left the department the patient is removed from the tracking board as a walk out and the chart is kept in the walk out folder located in triage. ... LWBS (Left without being seen): The patient arrived in the ED, received a triage assessment by the RN and left prior to the Medical Screening Exam. This patient will be called a minimum of every 15 minutes for three attempts. These attempts will be documented on the triage record. Once it is determined the patient has indeed left the department the patient is removed from the tracking board as LWBS. ..."

1. Review of Medical Records #1, #3, and #4, indicated the ED patients were not called to be seen every 15 minutes for three attempts, prior to documenting the patients LWBS or Walk Out, as per facility policy:

a. Patient #1 arrived to the ED via ambulance transport on 6/4/13 at 1420, and was triaged upon arrival. The Nursing Progress Notes indicates that the first call for Patient #1 to be seen was on 6/4/13 at 20:00, and the second call was on 6/4/13 at 20:00. The documented Disposition on 6/4/13 at 20:13 was LWBS.

b. Patient #3 arrived to the ED on 6/4/13 at 15:18. The Nursing Progress Notes indicates on 6/4/13 at 19:15 that Patient #3 left without being triaged.

i. The documentation in the 'Disposition' section, on 6/4/13 at 19:14, indicates LWBS. The patient left prior to triage and 'Walk Out' should have been documented as the Disposition, according to facility policy.

c. Patient #4 arrived to the ED on 6/4/13 at 15:27 and was triaged at 15:31. Per the Nursing Progress Notes, the first call for Patient #4 to be seen was at 18:46, and the second call was at 20:11. The documented Disposition on 6/4/13 at 20:15 was LWBS.

2. The above findings were reviewed with and confirmed by Staff #2 and Staff #3.

3. Review of the following Medical Records also lacked evidence of three call attempts every 15 minutes prior to documentation of the patient LWBS:

a. Review of Medical Record #23 indicated Patient #23 arrived to the facility on 7/8/13 at 11:04 AM and was triaged at 11:39 AM. Documentation in the medical record indicates the patient LWOB on 7/8/13 at 19:16. There was no evidence of two call attempts prior to documentation of LWOB.

b. Review of Medical Record #26 indicated Patient #26 arrived to the facility on 7/9/13 at 1717 and was triaged at 1725. Documentation in the medical record at 1937 indicates that the patient notified the greeter he/she was leaving, and was seen leaving the waiting room. A second call with no answer was documented at 2003, 26 minutes later. A third call was documented at 2321, 3 hours and 3 minutes after the second call.

c. Review of Medical Record #29 indicated Patient #29 arrived to the facility on 7/10/13 at 1317 and was triaged at 1320. Documentation in the medical record indicates at 1526 there was no answer when the patient was called. A second call with no answer was documented at 1603, 37 minutes later. A third call was documented at 1644, 41 minutes after the second call.

d. Medical Record #31 was reviewed and indicated Patient #31 arrived to the facility on 9/24/13 at 2139. Documentation in the medical record indicated Patient #31 was first called to be seen on 9/25/13 at 0015, and there was no answer. A second call with no answer was documented on 9/25/13 at 0150, 1 hour and 35 minutes after the first call. A third call was documented at 05:14, 3 hours and 24 minutes after the second call.

H. Based on medical record review, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure all policies and procedures are commensurate with the New Jersey Board of Nursing Statutes, Title 45, Chapter 11.

Findings include:

Reference #1: The New Jersey Board of Nursing Statutes at 45:11-23 states "... Definitions ... The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician ...". 45:11-49 states "... a. In addition to all other tasks which a registered professional nurse may, by law, perform, a nurse practitioner/clinical nurse specialist may manage specific common deviations from wellness and stabilized longterm illnesses by: (1) initiating laboratory and other diagnostic tests; and (2) prescribing or ordering medications and devices, as authorized by subsections b. and c. of this section ... c. A nurse practitioner/clinical nurse specialist may prescribe medications and devices in all other medically appropriate settings, subject to the following conditions: ... (2) the prescription is written in accordance with standing orders or joint protocols developed in agreement between a collaborating physician and the nurse practitioner/clinical nurse specialist, or pursuant to the specific direction of a physician; ..."

Reference #2: Facility policy and procedure titled 'Advanced Triage Protocol' states "Policy: Advanced triage Guidelines are guidelines for interventions, treatments, or procedures that may be performed for a range of patients who meet certain criteria and for whom certain circumstances exist. These protocols identify specific treatments for specific conditions that must exist prior to implementation. Knowledge, skill and judgement must be used by the Emergency Department nurse to determined when patients meet the pre-established criteria and whether or not the implementation of care protocols and interventions is appropriate. Procedure: 1. The RN triaging the patient will initiate the Guideline only after completing and documenting a thorough triage assessment. ... 3. The advanced guidelines are considered physician orders for specific patient complaints. ... 5. The ED RN will initiate the guidelines as outlined on the advanced triage guideline form. 6. The ED RN will consult with the physician when there is uncertainty as to whether an intervention should be completed. 7. The ED RN will document all interventions and medications as given on the physician order sheet and appropriate nursing forms."

1. On 3/24/14 at 10:15 AM the ED was toured in the presence of Staff #1 and Staff #2. The Greeter RN, Staff #16 was interviewed regarding his/her role in triage. Per Staff #16, the greeter nurse and the triage nurse may give certain medications to patients in triage, prior to the LIP evaluating the patient. Staff #16 demonstrated the Edims computer system, and the standing orders that the nurse can choose, from a drop down box, for specific signs or symptoms, or patient complaints. Examples include:

a. For a fever, the nurse may choose Ibuprofen or Acetaminophen to administer to the patient with a fever.

b. For Asthma, the nurse may administer Duo Nebs.

i. Albuterol presents with the doses of 1.25 mg or 2.5 mg. Per Staff #16, he/she would give the lower dose to a pediatric patient, and the higher dose to an adult.

c. For a UTI with fever, the options include acetaminophen, urine culture, BMP, CBC, Blood Cultures.

d. For abdominal pain with nausea, Ondansetron 4 mg is available as an option. Per Staff #16, she would also administer this medication to a pediatric patient, but would check with the MD if the patient was 6 months old or younger.

2. The facility is allowing the RNs to administer medications and order sets prior to the LIP's MSE of patients. The registered nurses that serve as the greeter RN and triage RN are not nurse practitioners or clinical nurse specialists, that are permitted per the New Jersey Board of Nursing Statutes to administer prescriptions and standing orders or joint protocols, that are developed in agreement with a collaborating physician.

3. A review of Medical Record #42 was completed. Per the triage nursing assessment, "upon arrival in triage pt with severly (sic) decreased lungs sounds and bilateral wheezing for past few days. pt reports he ran out of his neb treatments and has only been using his rescue inhaler with no improvement. pt immediately given duo nebs in triage breathing effort improved. pt reports tightness in chest improved with neb treatment and ability to speak improved."

a. The triage RN administered medications that are not in accordance with the New Jersey Board of Nursing Statutes.

b. There was no evidence the triage RN documented the duo neb medications as given on the physician order sheet, as per policy in reference #2.

i. Staff #15 reviewed Medical Record #42 and confirmed on 3/19/14 at 11:50 AM that the triage RN did not document the duo neb administration by using the drop down box in the standing orders.

4. A review of Medical Record #27 was completed. Per the triage nursing assessment, "Patient complaining of vomiting and diffuse abdominal pain ... Patient had an uncontrolled diarrhea episode in triage." The Triage RN gave Patient #27 Ondansetron 4 mg by mouth at 9:28 PM.

a. The triage RN administered medications that are not in accordance with the New Jersey Board of Nursing Statutes.

Based on a tour of the ED and staff interview conducted on March 19, 2014 at approximately 11:15 AM, it was determined that the facility failed to conspicuously post signage, specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions and women in labor, or information indicating whether or not the hospital participates in the Medicaid program.

Findings include:

1. Observation at the following entrances and areas of the ED lacked evidence of signs pertaining to EMTALA law, and information indicating whether or not the hospital participates in the Medicaid program:

a. The Grant Street entrance

b. The main entrance from the circular driveway

c. The main entrance to the ED

d. The main ED waiting area

e. The triage bays in the ED

f. The treatment bays in the ED

g. The fast track area

h. The pediatric treatment area

2. All of the above findings were confirmed by Staff #1.

Based on a review of the ED on-call lists, it was determined that the facility failed to ensure that a physician on call list that identifies the name of an individual physician on call for all specialties was maintained.

Findings include:

1. Review of the on call list for an ENT specialist revealed no physician names for November 2013 and for February 2014.

2. Review of the on call list for a Neuro-surgery specialist revealed no physician names for February 2014.

3. Review of the on call list for a Plastic/Wound specialist revealed no physician names for February 2014.

4. Review of the on call list for a Urology specialist revealed no physician names for February 2014.

5. The above findings were confirmed by Staff #1.

A. Based on review of facility policy and procedure, medical record review, and staff interview, it was determined that the facility failed to ensure that pregnant patients presenting to OB Triage are assigned an acuity level to prioritize when the individual will be seen by a physician or other QMP.

Findings include:

Reference: Facility policy and procedure titled "Guidelines for Assessment and Triage of Obstetric Patients" states, "1. Upon arrival to the Labor Triage Room, the registered nurse will perform a focused nursing assessment to verify the patient's clinical status ... 3. The registered nurse will give a patient status report to the physician (resident/attending), who will perform a medical screening exam (MSE) ..."

1. Lack of documentation in Medical Records #2, #6, #7, #8, #9, #10, #11, #13 and #14 indicated that the patients were not assigned an acuity level in OB triage.

2. Review of the policy and procedure referenced above, lacks evidence of a process to assign an acuity level to OB patients, so as to prioritize when the patient will be seen by a physician or other QMP.

3. This was confirmed by Staff #12.


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B. Based on medical record review, review of facility Medical-Dental Staff Rules and Regulations, and staff interview, it was determined that the facility failed to provide an evaluation by qualified medical personnel of all patients coming to the emergency department (ED).

Findings include:

Reference: Facility's Medical Dental-Staff Rules and Regulations state "... 24. Any patient who presents to the Emergency Department will be evaluated by an appropriately credentialed, qualified medical professional i.e., an Attending physician or Dentist, Physician Assistant, Nurse Practitioner, Hospitalist, or member of the Resident Physician House Staff. This medical screening examination will be appropriately documented in the patient's Emergency Department medical record for that visit."

1. Review of Medical Record #1 indicated Patient #1 arrived to the ED via ambulance transport on 6/4/13 at 1420, and was triaged upon arrival.

a. The Nursing Progress Notes indicated that the first call for Patient #1 to be seen was on 6/4/13 at 20:00. The documented Disposition on 6/4/13 at 20:13 was LWBS.

b. Patient #1 arrived to the facility on 6/4/13 at 1420 and was documented as LWBS at 2013, 5 hours and 40 minutes after his/her arrival. There was no evidence of a provision of a MSE to Patient #1 within 5 hours and 52 minutes from his/her arrival to the facility, to the time he/she LWBS.

c. The above findings were reviewed with and confirmed by Staff #2 and Staff #3.

2. Medical Record # 3 was reviewed on 3/19/14 and indicated Patient #3 arrived to the facility on 6/4/13 at 1518. Documentation in the medical record at 1915 indicated the patient left without being triaged. There was no evidence of a provision of a MSE to Patient #3, 3 hours and 40 minutes after his/her arrival to the facility.

3. Medical Record #4 was reviewed and indicated Patient #4 arrived to the facility on 6/4/13 at 1527 with complaints of a fall and right eye hematoma. Documentation in the medical record at 1846 indicated the patient was called to be seen and there was no answer. At 2015 the medical record indicated the patient left without being seen. There was no evidence of a provision of a MSE to Patient #4, from the time of his/her arrival, until the time of the first call at 1846, 3 hours and 19 minutes after his/her arrival to the facility.

4. Review of Medical Record #12 indicated Patient #12 arrived to the facility on 6/2/13 at 2:04 AM for complaints of suprapubic pain and nausea. Documentation in the medical record indicated the patient LWOB on 6/2/13 at 06:25. There was no evidence of a provision of a MSE to Patient #12 for 4 hours and 21 minutes, from the time of his/her arrival until the time he/she LWOB.

5. Review of the ED log indicated Patient #15 arrived to the facility on 6/2/13 at 01:54 and left without treatment at 05:14. There was no evidence of a provision of a MSE to Patient #15 for 3 hours and 20 minutes, from the time of his/her arrival until the time he/she LWOT.

6. Medical Record # 23 was reviewed and indicated Patient #23 arrived to the facility on 7/8/13 at 11:04 AM with complaints of dizziness X 2 weeks that was worsening that day. Documentation in the medical record indicated Patient #23 was triaged at 11:39 AM, and at 19:16 LWOB. There was no evidence of a provision of a an MSE to Patient #23 for 8 hours and 12 minutes, from the time of his/her arrival until the time it was documented he/she LWOB.

7. Medical Record #31 was reviewed and indicated Patient #31 arrived to the facility on 9/24/13 at 2139 with complaints of cervical cancer, pregnant, weakness, lightheadedness, pain 8/10. The patient was triaged at 2139, and per the triage assessment, the patient's family member reported that the patient has had intermittent headaches, that were worse that day with vomiting and hallucinations. The patient was triaged as an acuity level of 2-Emergent. Documentation in the medical record indicated Patient #31 was first called to be seen on 9/25/13 at 0015, and there was no answer. On 9/25/13 at 0514 the medical record indicates the patient LWOB. There was no evidence of a provision of a an MSE to Patient #31 for 2 hours and 47 minutes, from the time of his/her arrival to the time of his/her first call to be seen.

Based on medical record review, review of facility policy, and staff interview, it was determined that the facility failed to ensure that all patients that are transferred have a completed certification.

Findings include:

REFERENCE: Facility Policy: EMTALA Transfer, page 4 of 4, number 8 states "...The physician must list the risks and benefits to which this certification is based."

1. Medical Record #34 was reviewed. The patient was transferred to another facility for a higher level of care. There was no documentation on the transfer certification form stating the risks and benefits of transfer.

2. Medical Record #37 was reviewed. The patient was transferred to another facility for a higher level of care. There was no documentation on the transfer certification form stating the risks and benefits of transfer.

3. Staff #1 confirmed the above.