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Based on observation, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to conspicuously post signage, specifying the rights of individuals under section 1866 of the Act with respect to examination and treatment of emergency medical conditions and women in labor.

Findings include:

Reference: Facility policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA)" states, "... Procedure: 1.0 Signage with patient right to know will be posted in visible locations in the ED [Emergency Department]and Registration/Admitting Department, Outpatient Clinics, and areas of entry of ambulatory patients. ..."

1. A tour of the ED, conducted on January 2, 2020, revealed the following:

a. EMTALA signs were not posted in Bay 3A, Bay 4A, Bay 5A, Bay 6A, Bay 7A, Bay 8A, Bay 10A, Bay 11A, Bay 15A, Bay 16A, and Bay 19.

b. The EMTALA sign posted in the ED Waiting Room was not visible to all patients and visitors.

2. A tour of the Hospital Main Entrance, conducted on January 2, 2020, revealed that EMTALA signs were not posted at the hospital entrance or in the Hospital Main Lobby.

3. These findings were confirmed by Staff #5 and Staff #6.

Based on staff interview, review of facility policy and procedure, and review of the on-call list of physicians who were on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition for a two month period, it was determined that the facility failed to identify individual physician names on the list.

Findings include:

Reference: Facility policy titled "Emergency Room On-Call Obligation and Response Time" states,
"POLICY:
.....
1.3 Obligations of On-Call Physicians
For unassigned ER (Emergency Room) patients, private practice patients, or consultation requests, physicians are required to:
* Respond to the Emergency Room in a timely manner. After being contacted by the ED staff, the on-call physician must respond to the ED (Emergency Department) within 20 minutes .....
....."

1. Review of the Emergency Department on-call lists for the time frame between December 2019 and January 2020 revealed:

a. December 2019:

(i) The ENT (Ears, Nose & Throat) on-call list entries for 12/16 through 12/31 were entered as "ENT GROUP." The phone number listed was that of the physician group service.

(ii) The NEUROSURGERY on-call list entry for the entire month was entered as "____ Neurosurgical Group (Neurosurgical/Stroke Intervention)." The phone number listed was that of the physician group service.

(iii) The ORTHOPEDICS on-call list entry for the entire month was entered as "_____ ______ Orthopedics Group." The phone number listed was that of the physician group service.

(iv) The FOOT AND ANKLE on-call list entries for 12/1 through 12/5 and 12/13 through 12/17 were entered as "_____ ______ Orthopedic Group" and the entry listed for 12/18 through 12/24 was listed as "____ & _____ Specialists." The phone numbers listed were those of the physician group services.

(v) The PLASTIC SURGERY on-call list entries for 12/1 through 12/5, 12/11 through 12/20, and 12/23 through 12/27 were entered as "__________ and ________." The phone number listed was that of the physician group service.

(vi) The VASCULAR on-call list entries for 12/1 through 12/4, 12/6 through 12/12, 12/15 through 12/20, and 12/30 were entered as "The ______________ ____ Group." The phone number listed was that of the physician group service.

(vii) The UROLOGY on-call list entries for the entire month were entered as "___ ______ Urology." The phone number listed was that of the physician group service.

(viii) The MEDICINE on-call list entry for 12/31 was entered as "___________ Group." The phone number listed was that of the physician group service.

(ix) The NEUROLOGY on-call list entries for the entire month were entered as "Specialist on Call." The phone number listed was that of the physician group service.

(x) The GENERAL SURGERY on-call list entries for 12/2, 12/4, 12/8, 12/10 through 12/12, 12/16, 12/18, 12/20, 12/24, and 12/26 through 12/28 were entered as "________ ________ Associates."

b. January 2020:

(i) The ENT on-call list entries for 1/1 through 1/3 and 1/18 through 1/31 were entered as "ENT GROUP." The phone number listed was that of the physician group service.

(ii) The NEUROSURGERY on-call list entry for the entire month was entered as "____ Neurosurgical Group (Neurosurgical/Stroke Intervention)." The phone number listed was that of the physician group service.

(iii) The ORTHOPEDICS on-call list entry for the entire month was entered as "_____ ______ Orthopedics Group." The phone number listed was that of the physician group service.

(iv) The FOOT AND ANKLE on-call list entries for 1/1 through 1/5 and 1/13 through 1/26 were entered as "_____ ______ Orthopedic Group" and the entry listed for 1/8 through 1/12 was listed as "____ & _____ Specialists." The phone numbers listed were those of the physician group services.

(v) The PLASTIC SURGERY on-call list entries for 1/2, 1/8 through 1/9, 1/13 through 1/20, and 1/22 through 1/31 were entered as "__________ and ________." The phone number listed was that of the physician group service.

(vi) The VASCULAR on-call list entries for 1/1 through 1/5, 1/7 through 1/11, 1/13, 1/15 through 1/21, 1/23 through 1/29, and 1/31 were entered as "The ______________ ____ Group." The phone number listed was that of the physician group service.

(vii) The UROLOGY on-call list entries for the entire month were entered as "_______ Urology." The phone number listed was that of the physician group service.

(viii) The NEUROLOGY on-call list entries for the entire month were entered as "Specialist on Call." The phone number listed was that of the physician group service.

(ix) The GENERAL SURGERY on-call list entries for 1/1, 1/3 through 1/5, 1/9, 1/11, 1/13, 1/17, 1/19, 1/21, 1/25, and 1/27, and 1/29 were entered as "________ ________ Associates."

* The referenced policy and procedure states that the ED staff will contact the on-call physician, not the service of the group with whom multiple physicians belong.

** Individual physician names and phone numbers were not listed for all specialties on every day.

2. Administrator #1 stated that on dates where a physician group or multiple physicians are listed as the on-call physician, unless identified as 1st on-call or 2nd on-call, the hospital does not know who is the individual physician responsible for the on-call duty.

Based on staff interview, medical record review, and review of the Emergency Department Time Line Report, it was determined that the facility failed to ensure that all entries in the log are accurate in 18 out of 20 medical records reviewed.

Findings include:

1. Upon review of Medical Record #1, the following was noted:

a. The ED (Emergency Department) Physician Note indicated that the patient was seen by the physician on 12/20/19 at 5:01 PM.

b. The ED Time Line Report indicated that the "Time to Doctor" was 4:49 PM.

2. Upon review of Medical Record #2, the following was noted:

a. The ED Physician Note indicated that the patient was seen by the physician on 12/20/19 at 1:49 PM.

b. The ED Time Line Report indicates that the "Time to Doctor" was 1:43 PM.

3. Upon review of Medical Record #5, the following was noted:

a. There was no documentation in the ED Physician Notes indicating the time the patient was seen by the physician on 9/3/19. The facility staff stated that the time the physician orders were entered at 10:08 AM, is the time the patient was seen by the physician.

b. The ED Time Line Report indicates that the "Time to Doctor" was 9:55 AM.

4. Upon review of Medical Record #6, the following was noted:

a. The ED Physician Note indicated that the patient was seen by the physician on 8/10/19 at 10:08 PM.

b. The ED Time Line Report indicated that the "Time to Doctor" was 9:55 PM.

5. Upon review of Medical Record #7, the following was noted:

a. Documentation in the ED Physician Note indicated that the patient was seen by the physician on 8/10/19 at 3:40 PM.

b. The ED Time Line Report indicated that the "Time to Doctor" was 2:43 PM.

6. Upon review of Medical Record #8, the following was noted:

a. Documentation in the ED Nurses Note indicated that the patient left without being seen.

b. The ED Time Line Report indicated that the patient "Disposition" was TIP (Treatment in Progress).

7. Upon review of Medical Record #9, the following was noted:

a. There was no documentation in the ED Physician Notes indicating the time the patient was seen by the physician on 8/10/19. The facility staff stated that the time the physician orders were entered at 2:42 PM is the time the patient was seen by the physician.

b. The ED Time Line Report indicates that the "Time to Doctor" was 2:37 PM.

8. Upon review of Medical Record #10, the following was noted:

a. Documentation indicated that the patient left without being seen.

b. The ED Time Line Report indicated that the patient "Disposition" was WTBT (Waiting to be Triaged).

9. Upon review of Medical Record #11, the following was noted:

a. Documentation in the ED Physician Note indicated that the patient was seen by the physician on 7/4/19 at 1:07 PM.

b. The ED Time Line Report indicated that the "Time to Doctor" was 12:58 PM.

10. Upon review of Medical Record #12, the following was noted:

a. Documentation in the ED Physician Note indicated that the patient was seen by the physician on 7/4/19 at 11:56 AM.

b. The ED Time Line Report indicated that the "Time to Doctor" was 11:47 AM.

11. Upon review of Medical Record #13, the following was noted:

a. Documentation indicated that the patient left without being seen.

b. The ED Time Line Report indicated that the patient "Disposition" was WTBT (Waiting to be Triaged).

12. Upon review of Medical Record #14, the following was noted:

a. Documentation in the ED Physician Note indicated that the patient was seen by the physician on 7/4/19 at 10:46 AM.

b. The ED Time Line Report indicated that the "Time to Doctor" was 10:42 AM.

13. Upon review of Medical Record #16, the following was noted:

a. Documentation in the ED Physician Note indicated that the patient was seen by the physician on 9/3/19 at 10:03 AM.

b. The ED Time Line Report indicated that the "Time to Doctor" was 9:57 AM.

14. Upon review of Medical Record #17, the following was noted:

a. Documentation in the ED Physician Note indicated that the patient was seen by the physician on 9/3/19 at 10:47 PM.

b. The ED Time Line Report indicated that the "Time to Doctor" was 10:39 PM.

15. Upon review of Medical Record #18, the following was noted:

a. Documentation in the ED Physician Note indicated that the patient was seen by the physician on 10/14/19 at 8:44 PM.

b. The ED Time Line Report indicated that the "Time to Doctor" was 8:36 PM.

16. Upon review of Medical Record #19, the following was noted:

a. There was no documentation in the ED Physician Notes indicating the time the patient was seen by the physician on 11/28/19. The facility staff stated that the time the physician orders were entered at 5:09 PM is the time the patient was seen by the physician.

b. The ED Time Line Report indicated that the "Time to Doctor" was 4:45 PM.

17. Upon review of Medical Record #20, the following was noted:

a. There was no documentation in the ED Physician Notes indicating the time the patient was seen by the physician on 11/28/19. The facility staff stated that the time the physician orders were entered at 4:59 PM is the time the patient was seen by the physician.

b. The ED Time Line Report indicated that the "Time to Doctor" was 4:21 PM.

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

Based on staff interviews, medical record review, review of facility policy and procedure, and review of facility documents, it was determined that the facility failed to ensure that the code stroke protocol is implemented in 1 of 2 medical records reviewed.

Findings include:

Reference #1: Facility policy titled "Code Stroke Policy for Inpatient Nursing Units and Emergency Room" states, "... Following action must take place as soon as Code Stroke is activated. ... Call ... Teleneurology to initiate consult. ... The Teleneurologist will perform the initial assessment including NIHSS (The National Institute of Health Stroke Scale) of the stroke patient and provide recommendation for the treatment with IV (intravenous) TPA (Tissue Plasminogen Activator) ... "

Reference #2: Facility document titled "Specialist on Call Service Agreement" states, "... NJTP (New Jersey Tele-Physicians) ... Physician Services ... will be capable of initiating Specialty Consultative Service within 30 minutes of being paged ..."

1. Upon review of Medical Record #1, the following was noted:

a. On 12/20/19 at 4:34 PM, the patient was transported to the Emergency Department (ED) via ambulance with complaints of right sided weakness and dizziness.

b. According to the ED triage note at 4:46 PM, "... Denies any tingling and numbness. Denies headache. ... no neuro deficits noted. ... ESI [Emergency Severity Index] Acuity Level 3 ..."

c. According to the ED Physician Notes, "Family arrived at bedside and states patient's speech is not at baseline, which was previously reported as baseline by his wife. Family member is a Registered Nurse, and also notes right hand weakness. On repeat physical exam, patient does have right-sided weakness with 3/5 strength in RUE (right upper extremity) and 4/5 strength in RLE (right lower extremity) with what appears to be a change in speech pattern and dysarthria. ..."

d. At 7:45 PM, a Code Stroke was called due to new onset right arm weakness.

e. Teleneurology was called at 7:55 PM.

f. The ED Physician Note states, "... there is no available neurologist ... patient to be transferred ... in the best interest of patient's care ... clinical impression is .. R/O (rule out) stroke ..."

g. The Patient Transfer Order and Physician Certification (Form #2) states, " ... Benefits of Transfer ... Physician specialists needed are not available ... Specialty not available: Neuro (Neurology). ..."

h. The patient was transferred at 9:33 PM, one hour and thirty eight minutes after Teleneurology was called.

i. The Teleneurologist did not perform the initial assessment.

j. The Physician Specialty Consultative Services were not initiated within 30 minutes.

2. Upon interview, Staff #1 stated, "The Teleneurologist should have seen the patient."

3. There was no documentation indicating why the consult was not performed.

4. The above findings were confirmed by Staff #1 and Staff #6.

Based on staff interview and medical record review, it was determined that the facility failed to ensure transfer forms are complete for all patients that are transferred to another facility in 1 out of 5 medical records reviewed.

Findings include:

1. Upon review of Medical Record #1, the following was noted:

a. The Patient Consent for Transfer (Form #1) was incomplete in the following areas:

(i) The box for "Patient Consent to Transfer" was not checked.

(ii) The box indicating that the receiving hospital/physician agreed to accept the patient in transfer was not checked.

2. The above findings were confirmed by Staff #1 and Staff #6.