HospitalInspections.org

Based on medical record (MR) review, document review and interview, the hospital did not comply with the requirements at 489.24 and 489.20, Specifically, 1) The hospital did not enter complete information about a patient (Patient #1) into the Emergency Department (ED) Central Log and also cancelled her from their ED Central Log. 2) The hospital did not provide a medical screening exam (MSE) to Patient #1, who presented to the ED for evaluation to determine if an emergency medical condition (EMC) existed. 3) The facility sent Patient #1 to another hospital (Hospital B) when the hospital had capacity and capability to treat and admit the patient and the transfer procedure was not followed. This could lead to untoward patient outcomes. Please reference findings at Tag 2405, Tag 2406 and Tag 2409.

Based on document review and interview, the hospital did not ensure that it entered complete information into the ED Central Log for Patient #1 when she presented to the Emergency Department (ED) for evaluation. Additionally, the facility's policy and procedure (P&P) does not address the requirements for the documentation in the ED Central Log. This could cause patients to not receive the required treatment.

Findings include:

-- Review of the facility's P&P titled "Emergency Department: Triage," reviewed 10/2021, indicated triage will occur after the patient is identified and placed into the medical record (MR). Full registration routinely takes place at the bedside after a medical screening exam (MSE) has been completed."

-- Review of the hospital's ED Central Log revealed, Patient #1 presented to the ED on 2/9/2023 at 9:45 pm. A registered nurse (RN) was assigned to the patient at 9:51 pm. The nurse was removed from the patient's MR at 10:12 pm and the documentation indicated "admission (Cancelled)." There was no documentation of a chief complaint, discharge diagnosis, time of discharge, or disposition.

-- During interview of Staff A, Accreditation Specialist on 6/20/2023 at 11:55 am, he/she acknowledged the above findings.

Based on document review, medical record (MR) review and interview, in 1 of 20 MRs reviewed, a patient (Patient #1) did not receive a medical screening exam (MSE) to determine if an emergency medical condition (EMC) existed. This could lead to untoward patient outcomes.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled, "Emergency Patient Screening Guidelines," revised 4/2023, indicated according to emergency medical treatment and labor act (EMTALA), if any individual comes to the hospital emergency department (ED) and requests examination or treatment for a medical condition the hospital must provide, without discrimination, an appropriate MSE to determine whether an EMC exists.

-- Review of the P&P titled, "Suicide Risk Screen and/or Transfer of Patient to CPEP (Comprehensive Psychiatric Emergency Program)," revised 10/2020, indicated "any patient who presents to the ED can be sent directly to CPEP for a follow-up psychiatric exam when it has been determined that the patient does not require medical attention or does not meet exclusionary criteria below:

- Temperature above 101 degrees fahrenheit, pulse above 120, systolic blood pressure less than 95 or greater than 180, oxygen
saturation less than 92%, glucose greater than or equal to 300
- Signs of intoxication, slurred speech, euphoria, impaired balance, erratic behavior, or ethanolic odor
- Patient post ingestion
- Justice Center Referrals
- Altered mental status related to medical illness
- Pregnant with no prenatal care
- Injury that requires treatment
- Recent sexual assault without exam
- From a skilled nursing facility

At the time of transfer the ED nurse should contact the ED Patient Access Department to have the patient quick registered to the CPEP tracking board. The nurse should complete the CPEP Medical Exclusionary Criteria in MR. The CPEP nurse should call ED nurse with any questions. Security should escort patient to CPEP along with appropriate staff."

-- Review of Patient #1's MR revealed, Patient #1 presented to the ED on 2/9/2023 at 9:45 pm. A registered nurse (RN) was assigned to the patient at 9:51 pm. The nurse was removed from the patient's MR at 10:12 pm and the documentation indicated admission (Cancelled). The MR lacked documentation of any assessment by an RN or completion of the CPEP Medical Exclusionary Criteria in MR. Additionally there was no documentation that a MSE was performed by an appropriate provider.

-- Review of Patient #1's MR from Hospital B revealed, on 2/9/2023 at 10:33 pm, Patient #1 (13-year-old female) presented to the ED at Hospital B for a psychiatric evaluation. Initially she was brought to St. Joseph's Hospital Health Center (SJHHC) CPEP unit, however, per EMS they refused her there and sent her out to Hospital B.

The EMS report indicated law enforcement had placed the patient under arrest, under the Mental Hygiene Law 9.41 (Section 9.41 authorizes a peace officer or police officer to take into custody, for the purpose of a psychiatric evaluation, an individual who appears to be mentally ill and is conducting themselves in a manner likely to result in serious harm to self or others). While transporting the patient, she tried to kick out the window of the back door of the vehicle and was not able to be calmed. EMS was called at that time to assist with transport to SJHHC CPEP unit. The patient was handcuffed which made it difficult to do vital signs and was then placed in soft wrist restraints ... "The foster mother then requested the patient be transported to CPEP at SJHHC this time to see if they could help her better." EMS arrived at SJHHC ED where Patient #1 was registered. The charge nurse had security bring EMS, law enforcement and the patient, who was restrained on the stretcher, to the CPEP unit. Once on the unit, 2 providers discussed the patient and waited for the foster mother to arrive. After a discussion with the foster mother, one of the providers instructed EMS to take the patient to Hospital B.

-- Per interview of Staff B, Registered Nurse (RN) Coordinator on 6/20/2023 at 10:20 am, Patient #1 came to CPEP with EMS and police on a stretcher. The foster mother was checking in with security. Two psychiatrists discussed that the patient was recently discharged from Hospital B after a long admission. They talked with the foster mother and then they said she wanted the patient brought to Hospital B. Staff B questioned if it was an EMTALA and was told it was the foster mother's decision to go to Hospital B. The patient was registered and put on their board, but no assessment was done. Approximately 1 week later it was discussed with staff about the lack of a MSE and lack of any transfer paperwork.

-- Per interview of Staff C, Psychiatrist on 6/20/2023 at 3:30 pm, Patient #1 was a child who had been an inpatient at another hospital (Hospital B) for several months. Within 24 hours of discharge, Patient #1 had a behavioral health issue, the family reached out for guidance and called 911. They were told to go to CPEP with law enforcement. Staff C spoke with the foster mother who was unsure why they went there (SJHHC). Discussed whether they wanted to remain in CPEP or go to Hospital B. Then Staff C asked the police if they could take the patient to Hospital B. The CPEP Medical Director was notified for input. The patient was not admitted to CPEP and was sent to Hospital B.

-- Per interview of Staff D, Psychiatrist on 6/20/2023 at 4:05 pm, there was a lot of commotion when Patient #1 arrived on a stretcher. The mother was upset. The patient had just been discharged the day before from Hospital B after 212 days. Staff D thought it was best for the patient to go back to Hospital B where the patient could be better served because they knew the history. Staff D did not talk to the patient or examine her. Staff D felt the EMTALA regulation did not make sense. The patient needed to go back the hospital she had been at. It had been less than 24 hours and they (SJHHC) would be starting from scratch. Staff D felt the patient came to the wrong place and felt it would benefit the patient to return to Hospital B.

-- During interview of Staff E, Chief Medical Officer on 6/21/2023 at 2:32 pm, he/she reviewed the case and indicated the patient came to CPEP instead of Hospital B. No MSE was performed. Any patient that crosses the threshold of the facility should have a MSE.

-- Per interview of Staff F, RN on 6/21/2023 at 2:55 pm, this patient had been at Hospital B for an extended period. The providers felt it was a failed discharge. The guardian who was with the patient and the two psychiatrists had a discussion. The patient was then sent to Hospital B. Staff F did not agree with the decision and spoke with the charge nurse.

Based on document review and interview, a patient (Patient #1) who presented to the Comprehensive Psychiatric Emergency Program (CPEP) unit was directed to another facility (Hospital B) for treatment, without a MSE or an appropriate transfer. This could cause patients to not receive appropriate care and untoward patient outcomes.

Findings include:

-- Review of the hospital's Emergency Department (ED) Central Log revealed, Patient #1 presented to the ED on 2/9/2023 at 9:45 pm. A registered nurse (RN) was assigned to the patient at 9:51 pm. The nurse was removed from the patient's MR at 10:12 pm and the documentation indicated "admission (Cancelled)."

-- Review of the facility's policy and procedure (P&P) titled, "Transfers To and From Another Facility," revised 3/2022, indicated prior to patient transfer from the ED to another acute care hospital the following must be completed and documented:
- Determination about the patient's condition made by a qualified provider and documented in the patient's MR and transfer record.
- A physician at the receiving hospital has agreed in advance to accept the patient.
- Transfer order and written transport orders documented on the "Patient Transfer Record" by a physician.
- Informed Consent signed by the patient or authorized decision maker.
- Records prepared and sent to accepting facility.
- Nurse to nurse report.
- Assessment of the patient prior to transport.

-- Per interview of Staff C, Psychiatrist on 6/20/2023 at 3:30 pm, Patient #1 was a child who had been an inpatient at another hospital (Hospital B) for several months. Within 24 hours of discharge Patient #1 had a behavioral health issue, the family reached out for guidance and called 911. They were told to go to CPEP with law enforcement. Staff C spoke with the foster mother who was unsure why they went here (St. Joseph's Hospital Health Center). Discussed whether they wanted to remain in CPEP or go to Hospital B. Then Staff C asked the police if they could take the patient to Hospital B. The CPEP Medical Director was notified for input. The patient was not admitted to CPEP. Patient #1 was transported by EMS to Hospital B. No transfer paperwork was completed.