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Based on interview and record review the provider failed to maintain a central log on each individual who comes to the emergency department. Specifically, the provider failed to document when individuals presented to the hospital, and whether each individual was admitted, transferred or discharged.

Findings:

On 12/18-19/12 the central logs for the Emergency Department (ED) and Labor and Delivery (L&D) unit were reviewed. Three (3) pages of the ED log failed to identify the date the patient presented to the hospital. The ED log also failed to document the admission, transfer or discharge for each patient.

The ED log consisted of unbound sheets of 11 by 17 inch paper. Each sheet contained 14 columns of information pertainng to ED visits. The log form did not contain a key or description of the data required for each column. One column was labeled "D/S". The top of each sheet contained a line labeled "Date". Each sheet contained rows for 32 patient entries.

Facility policy and procedure #15-C-2, titled "EMTALA-Central Log" (effective 10/18/10) was reviewed. The policy describes the regulatory requirement to track patients presenting with emergency medical conditions to the ED and L&D unit. The policy states the log must contain specific information about whether each patient was admitted, transferred or discharged. The policy does not provide a key to the columns on the ED log form.

During interview on 12/19/12 at 11:00 am the ED Nurse Director stated the "D/S" column was used to document patient disposition/status. She stated a check mark meant the patient was discharged from the ED. The letter "A" within a circle meant the patient was admitted. No further definitions were provided for the column labeled "D/S".

The following log deficiencies were identified:

1. On 6/13/12 a patient was brought to the ED by police. Column D/S was blank.

2. On 6/19/12 a male patient presented to the ED. Column D/S stated "crisis".

3. On 6/28/12 a 24 year old male presented to the ED. Column D/S stated "crisis". Medical record review determined the patient was discharged.

4. On 7/28/12 a 40 year old female presented to the ED. Column D/S was blank. Medical record review determined the patient was discharged.

5. On 8/9/12 a 9 year old female presented to the ED. Column D/S was blank. Medical record review determined the patient was discharged.

6. On 8/29/12 a 72 year old female presented to the ED. Column D/S was blank. Medical record review determined the patient was discharged.

7. On 12/14/12 a 27 year old male presented to the ED. Column D/S stated "crisis". Medical record review determined the patient was discharged.

8. On 12/14/12 a 20 year old male presented to the ED. Column D/S stated "crisis". Medical record review determined the patient was admitted.

9. A log page with 33 patient entries was not dated.

10. A page was labeled as "Sunday June 24". The year was not documented.

11. A page was labeled as "Sunday 24th, 2012, Pg # 1". The month was not documented.

During interview on 12/19/12 at 1:45 pm the Vice President of Performance Improvement confirmed the lack of complete documentation in the ED log regarding admission, transfer or discharge, and the lack of complete date entries.

Based upon interview and record review the provider failed to provide an appropriate medical screening examination (MSE), within the provider's capability, for 4 of 22 patients reviewed, and failed to document a timely MSE for 1 of 22 patients reviewed.

Findings:

Patient # 1

On 4/3/11 at 6:30 pm, a 30 year old male was transported by NYS Police to the MI Bassett Hospital Emergency Department (ED). The police were notified by the patient's mother that he stated that he wanted to harm himself and had left a note. The police took the patient into custody under the provisions of NYS Mental Hygiene Law. The police documented the patient wanted to harm himself, and had left a message stating he was going to harm himself.

"The Emergency Department Nurse's Note" documents the patient's history was significant for anxiety, cancer, divorce, stress, depression and a suicide attempt. Six (6) months prior the patient attempted suicide by shooting himself in the mouth. The patient admitted to drinking alcohol. His blood alcohol level (BAL) collected at 7:27 pm was 137 mg/dl (reference: legal intoxication for DWI >80 mg/dl).

The "Emergency and Trauma Service Physician's Note" (Physician's Note) at 7:55 pm documented the patient's chief complaint as suicidal ideation. The physician agreed with the nurse's note for the past history, social history and medications. The "Physician's Note" documents a review of systems, all checked for normal findings. General physical exam documented the patient was alert and oriented with the remainder of the examination checked as normal. The system marked "psychiatric" was checked as normal, with no documentation of any abnormalities.

A "Psychiatric Crisis Adult Assessment" was completed by a RN. The RN documented the patient admitted he had tried to commit suicide six months prior by shooting himself in the mouth. The patient believed his wife called the police and was using an "old" suicide note for custody of their children. A custody hearing was scheduled for 4/12/11. He worked nights and needed to go to work that night or lose his job. He also believed his wife called the police so that he would lose his job, and to make his life more difficult. The RN documented the Axis diagnoses included history of depression with suicidal ideation and acute intoxication. The electronic medical record reflected the RN assessment was recorded at 11:08 pm. Disposition from the ED was documented by the RN as collaboration with a psychiatrist, patient contract for safety, and discharge when the BAL was below 100. At 9:40 pm the RN documented that the patient was improved and discharged from the ED.

The medical record does not contain a psychiatric diagnosis, treatment plan, instructions or disposition/discharge order by a physician or other qualified member of the medical staff. On 4/6/11 the patient committed suicide.

Patient # 4

On 6/26/12 a 19 year old patient, who was 31 weeks pregnant, presented to the labor and delivery (L&D) unit for evaluation of occasional lower abdominal pressure. At 2:13 pm nursing documented on the "Obstetrical Outpatient Record" an assessment of the patient's vital signs.

The "Obstetrical Outpatient Record" has a line labeled "Time In:___". This is blank. The line labeled "Time Out:______" is blank. In the area of the form labelled "Physician Record" there is line labelled "Time Seen:_____". This line is blank. In the area of the form labelled "Nurses Notes" there is a line for "Time:____" and "Signature_____." There is no information entered here.

The provider failed to document a timely MSE for a pregnant patient.

Patient # 5

On 6/28/12 at 10:00 pm, a 24 year old male, with diagnoses of anxiety and suicidal ideation, was received via ambulance as the result of a transfer from another hospital. ED medical staff performed a MSE at 11:25 pm, and ordered laboratory studies. The chief complaint was documented as anxiety. The documentation of history noted post-traumatic stress disorder (PTSD) and anxiety with no active medical problems except high blood pressure.

The physician documented " - (symbol for negative) suicide, - (symbol for negative) homicidal. Able to care for self ". The physician agreed with the nurse ' s note for the past history, social history and medications. The "Emergency and Trauma Service Physician's Note" included a "Review of Systems" chart, which contained no documentation. A box labeled "All other Systems Reviewed are Negative" was checked. General physical examination documented that the patient had high blood pressure and increased pulse rate. The system marked "psychiatric"documented that the patient was alert and oriented, with normal memory, mood and affect. "Anxious" was documented as an abnormality. Diagnoses were documented as "anxiety" and "medical eval for Ø" (Psi, Greek letter used as a symbol for psychiatry).

An "Admission Crisis Center Adult Assessment" was completed by a RN at 4:40 am on 6/29/12. The nurse documented that the patient had a previous inpatient psychiatric admission in May 2011, and was working with his psychiatric provider to find the right combination of medications to relieve his symptoms. The patient denied suicidal ideation but admitted to a history of self-injurious behavior, "mostly cutting". The "Suicide Risk Assessment Scale" contained no documentation. The RN documented the Axis diagnoses included anxiety by history and PTSD. The section labeled "The clinical findings have been reviewed and assessed by:___" contained no documentation.

Disposition from the ED was documented by the RN as stable, discharged, and instructions given and understood. The patient was discharged at 10:15 am 6/29/12. The "Emergency and Trauma Services Discharge Instruction Sheet" (Instruction Sheet) contained follow-up instructions and a line for documentation of the nurse's signature, date and time. The line for the nurse's signature was completed and signed by an unlicensed staff member. The Instruction Sheet did not contain the signature of a nurse.

The unlicensed staff member was interviewed regarding their responsibilities during the facility tour on 12/18/12 at 10:45 am. The unlicensed staff member is a Transportation Coordinator for the Crisis Unit. The unlicensed staff member said they gathered information for the medical record and entries were reviewed by a nurse.

The medical record does not contain a psychiatric treatment plan, instructions or disposition/discharge order by a physician or other qualified member of the medical staff.

Patient #12

On 8/19/12 at 4:32 pm, a 41 year old male with a chief complaint of "psych eval" and "suicidal" was transported by the police to the ED. The patient had a history of bipolar disorder, had recently become homeless and stated to a family member that he wanted to "cut his wrists". The patient had been prescribed an opiate (Vicodin) for pain relief on 8/14/12, no other medications were documented. The patient reported using marijuana for pain control.

ED medical staff performed a MSE at 5:00 pm and ordered laboratory studies. Chief complaint was documented as suicidal threat and prescription drug abuse. In the "Emergency and Trauma Service Physician's Note, Review of Systems", a check mark was noted for Psychiatric, bipolar. The comments section documented "as above", and no additional information was documented. The physician agreed with the nurse's note for past history, social history, medications and allergies. The general physical exam was documented as normal and the system marked "psychiatric" documented the patient was alert and oriented with normal memory. The physician documented in the "Abnormalities/ Comments" section, "disheveled, thin male, speech somewhat pressured, unfocused" . Diagnosis was documented as "suicide threat- fried".

Urine drug screen collected at 4:45 pm was positive for benzodiazepines (sedative, anti-anxiety).

An "Admission Crisis Center Adult Assessment" was completed by an unlicensed staff member at 6:16 pm. Documentation noted, "The police stated 'There were about 25 empty prescription bottles in the home. The patient took 20 Vikodin [sic] yesterday B/C his back hurts. The patient agrees he abuses his pain medications". The patient's history included inpatient psychiatric admissions as a child and young adult. The "Suicide Risk Assessment Scale" contained no documentation. The unlicensed staff member documented the Axis diagnoses as polysubstance abuse by history, chronic pain and homeless. The "Global Assessment of Functioning" (GAF) score was documented as 45. (NB: The Global Assessment of Functioning (GAF) assigns a clinical judgment in numerical fashion to the individual's overall functioning level. Impairments in psychological, social and occupational/school functioning are considered, but those related to physical or environmental limitations are not. The scale ranges from 0 (inadequate information) to 100 (superior functioning)).

A RN note, dated 8/20/12 (untimed), documented that the nurse discussed the patient's case with an attending psychiatrist, who concurred with the plan for discharge. The nurse documented that the patient was stable and discharged at 9:45 am on 8/20/12.

The unlicensed staff member was interviewed regarding their responsibilities during the facility tour on 12/18/12 at 10:45 am. The unlicensed staff member is a Transportation Coordinator for the Crisis Unit. The unlicensed staff member said they gathered information for the medical record and entries were reviewed by a nurse.

No nursing assessment was documented after the patient was triaged by a RN at 4:33 pm on 8/19/12. The medical record does not contain a psychiatric treatment plan, instructions or disposition/discharge order by a physician or other qualified member of the medical staff.

Patient # 15

On 10/30/12 at 7:00 am a 28 year old patient, who was 33 weeks pregnant with twins, presented to the L&D unit reporting spontaneous rupture of membranes at approximately 6:45 am. At 7:30 am nursing documented on the "Obstetrical Outpatient Record" assessment of the patient's vital signs and fetal heart rates for both babies. There is no documentation of a MSE by a physician or other qualified member of the medical staff. The patient was transferred to another facility at 9:30 am.

Policy and Procedure

Provider policy and procedure # 15-C-5, "EMTALA- Medical Screening Exam" (effective date 10/18/10) was reviewed. The policy defines "Qualified Medical Person or Personnel" (QMP) as a specifically designated individual, other than a licensed physician, who is licensed or certified in one of the following professional categories and who has demonstrated current competence in the performance of medical screening examinations. Certified Nurse Midwives, and Physician Assistants and Nurse Practitioners assigned to the ED are the categories of professionals who have been approved by the Executive Committee of the Medical Staff as qualified to administer medical screening examinations.

Interview of the Chief of Emergency Services on 12/18/12 at 10:30 am revealed that psychiatric crisis patients presenting to the ED are medically cleared by the ED physician. An acute medical condition such as drug overdose may be medically managed in the ED by the ED physician. Intoxication may be co-managed by the ED physician and Psychiatry. The Psychiatry Department controls the Crisis Unit and is responsible for the patient's psychiatric evaluation. ED physicians do not discharge patients from the Crisis Unit.

The Chief of Psychiatry was interviewed on 12/18/12 at 1:00 pm. Interview revealed that when a patient presents to the ED for psychiatric evaluation, the "assumption is the patient is medically cleared first", and this determination is made by the ED physician. The patient then undergoes a psychiatric evaluation. The psychiatric provider does not issue the patient's discharge order. The psychiatric provider "rarely discusses" the patient's psychiatric evaluation with the ED physician and "90% of the time there is no collaboration with the ED physician".

The Crisis Unit RN was interviewed regarding their responsibilities during the facility tour on 12/18/12 at 11:00 am. The RN only works in the Crisis Unit and does not work within the ED proper. RNs staffing the Crisis Unit have a psychiatric background. The RN stated that during most evenings, nights and weekends, Crisis Unit nurses confer with a psychiatrist on the phone. Psychiatrists are not usually present in the Unit during these time periods. Psychiatrists frequently direct the Crisis Unit nurses over the phone.

On 12/19/12 at 11:00 am the Vice President for Performance Improvement stated Crisis Unit nursing staff have not been designated by the Board as QMPs.

Based on interview and record review the provider failed to effect an appropriate discharge of 3 of 22 patients reviewed. Additionally, the provider failed to effect an appropriate transfer through qualified personnel and transportation equipment for 2 of 22 patients reviewed.

Findings:


Patient # 1

On 4/3/11 at 6:30 pm, a 30 year old male was transported by NYS Police to the MI Bassett Hospital Emergency Department (ED). The police were notified by the patient's mother that he stated that he wanted to harm himself and had left a note. The police took the patient into custody under the provisions of NYS Mental Hygiene Law. The police documented the patient wanted to harm himself, and had left a message stating he was going to harm himself.

"The Emergency Department Nurse's Note" documents the patient's history was significant for anxiety, cancer, divorce, stress, depression and a suicide attempt. Six (6) months prior the patient attempted suicide by shooting himself in the mouth. The patient admitted to drinking alcohol. His blood alcohol level (BAL) collected at 7:27 pm was 137 mg/dl (reference: legal intoxication for DWI >80 mg/dl).

The "Emergency and Trauma Service Physician's Note" (Physician's Note) at 7:55 pm documented the patient's chief complaint as suicidal ideation. The physician agreed with the nurse's note for the past history, social history and medications. The "Physician's Note" documents a review of systems, all checked for normal findings. General physical exam documented the patient was alert and oriented with the remainder of the examination checked as normal. The system marked "psychiatric" was checked as normal, with no documentation of any abnormalities.

A "Psychiatric Crisis Adult Assessment" was completed by a RN. The RN documented the patient admitted he had tried to commit suicide six months prior by shooting himself in the mouth. The patient believed his wife called the police and was using an "old" suicide note for custody of their children. A custody hearing was scheduled for 4/12/11. He worked nights and needed to go to work that night or lose his job. He also believed his wife called the police so that he would lose his job, and to make his life more difficult. The RN documented the Axis diagnoses included history of depression with suicidal ideation and acute intoxication. The electronic medical record reflected the RN assessment was recorded at 11:08 pm. Disposition from the ED was documented by the RN as collaboration with a psychiatrist, patient contract for safety, and discharge when the BAL was below 100. At 9:40 pm the RN documented that the patient was improved and discharged from the ED.

The medical record does not contain a psychiatric diagnosis, treatment plan, instructions or disposition/discharge order by a physician or other qualified member of the medical staff. On 4/6/11 the patient committed suicide.


The provider failed to ensure an appropriate MSE was performed to determine if the patient's condition was stabilized prior to discharge.


Patient # 5

On 6/28/12 at 10:00 pm, a 24 year old male, with diagnoses of anxiety and suicidal ideation, was received via ambulance as the result of a transfer from another hospital. ED medical staff performed a MSE at 11:25 pm, and ordered laboratory studies. The chief complaint was documented as anxiety. The documentation of history noted post-traumatic stress disorder (PTSD) and anxiety with no active medical problems except high blood pressure.

The physician documented " - (symbol for negative) suicide, - (symbol for negative) homicidal. Able to care for self ". The physician agreed with the nurse ' s note for the past history, social history and medications. The "Emergency and Trauma Service Physician's Note" included a "Review of Systems" chart, which contained no documentation. A box labeled "All other Systems Reviewed are Negative" was checked. General physical examination documented that the patient had high blood pressure and increased pulse rate. The system marked "psychiatric"documented that the patient was alert and oriented, with normal memory, mood and affect. "Anxious" was documented as an abnormality. Diagnoses were documented as "anxiety" and "medical eval for Ø" (Psi, Greek letter used as a symbol for psychiatry).

An "Admission Crisis Center Adult Assessment" was completed by a RN at 4:40 am on 6/29/12. The nurse documented that the patient had a previous inpatient psychiatric admission in May 2011, and was working with his psychiatric provider to find the right combination of medications to relieve his symptoms. The patient denied suicidal ideation but admitted to a history of self-injurious behavior, "mostly cutting". The "Suicide Risk Assessment Scale" contained no documentation. The RN documented the Axis diagnoses included anxiety by history and PTSD. The section labeled "The clinical findings have been reviewed and assessed by:___" contained no documentation.

Disposition from the ED was documented by the RN as stable, discharged, and instructions given and understood. The patient was discharged at 10:15 am 6/29/12. The "Emergency and Trauma Services Discharge Instruction Sheet" (Instruction Sheet) contained follow-up instructions and a line for documentation of the nurse's signature, date and time. The line for the nurse's signature was completed and signed by an unlicensed staff member. The Instruction Sheet did not contain the signature of a nurse.

The unlicensed staff member was interviewed regarding their responsibilities during the facility tour on 12/18/12 at 10:45 am. The unlicensed staff member is a Transportation Coordinator for the Crisis Unit. The unlicensed staff member said they gathered information for the medical record and entries were reviewed by a nurse.

The medical record does not contain a psychiatric treatment plan, instructions or disposition/discharge order by a physician or other qualified member of the medical staff.

The provider failed to ensure an appropriate MSE was performed to determine if the patient's condition was stabilized prior to discharge.

Patient #12

On 8/19/12 at 4:32 pm, a 41 year old male with a chief complaint of "psych eval" and "suicidal" was transported by the police to the ED. The patient had a history of bipolar disorder, had recently become homeless and stated to a family member that he wanted to "cut his wrists". The patient had been prescribed an opiate (Vicodin) for pain relief on 8/14/12, no other medications were documented. The patient reported using marijuana for pain control.

ED medical staff performed a MSE at 5:00 pm and ordered laboratory studies. Chief complaint was documented as suicidal threat and prescription drug abuse. In the "Emergency and Trauma Service Physician's Note, Review of Systems", a check mark was noted for Psychiatric, bipolar. The comments section documented "as above", and no additional information was documented. The physician agreed with the nurse's note for past history, social history, medications and allergies. The general physical exam was documented as normal and the system marked "psychiatric" documented the patient was alert and oriented with normal memory. The physician documented in the "Abnormalities/ Comments" section, "disheveled, thin male, speech somewhat pressured, unfocused" . Diagnosis was documented as "suicide threat- fried".

Urine drug screen collected at 4:45 pm was positive for benzodiazepines (sedative, anti-anxiety).

An "Admission Crisis Center Adult Assessment" was completed by an unlicensed staff member at 6:16 pm. Documentation noted, "The police stated 'There were about 25 empty prescription bottles in the home. The patient took 20 Vikodin [sic] yesterday B/C his back hurts. The patient agrees he abuses his pain medications". The patient's history included inpatient psychiatric admissions as a child and young adult. The "Suicide Risk Assessment Scale" contained no documentation. The unlicensed staff member documented the Axis diagnoses as polysubstance abuse by history, chronic pain and homeless. The "Global Assessment of Functioning" (GAF) score was documented as 45. (NB: The Global Assessment of Functioning (GAF) assigns a clinical judgment in numerical fashion to the individual's overall functioning level. Impairments in psychological, social and occupational/school functioning are considered, but those related to physical or environmental limitations are not. The scale ranges from 0 (inadequate information) to 100 (superior functioning)).


A RN note, dated 8/20/12 (untimed), documented that the nurse discussed the patient's case with an attending psychiatrist, who concurred with the plan for discharge. The nurse documented that the patient was stable and discharged at 9:45 am on 8/20/12.


The unlicensed staff member was interviewed regarding their responsibilities during the facility tour on 12/18/12 at 10:45 am. The unlicensed staff member is a Transportation Coordinator for the Crisis Unit. The unlicensed staff member said they gathered information for the medical record and entries were reviewed by a nurse.


No nursing assessment was documented after the patient was triaged by a RN at 4:33 pm on 8/19/12. The medical record does not contain a psychiatric treatment plan, instructions or disposition/discharge order by a physician or other qualified member of the medical staff.

The provider failed to ensure an appropriate MSE was performed to determine if the patient's condition was stabilized prior to discharge.


Patient #14

On 9/16/12 at 3:30 PM a 15 year old male patient presented via ambulance to the Emergency Department (ED). The patient was a known diabetic and was complaining of nausea and vomiting. ED medical staff performed a medical screening examination. Medical staff ordered laboratory studies, an EKG, and intravenous fluids and medications.

The "Emergency Department Nurse's Note", page 2, contains a line labeled "Mode of Departure". A check mark is in a box labeled "Ambulance". The next line on page 2 is labeled "Condition on Departure". A check mark is in a box labeled "Critical". The page is signed by a Registered Nurse.

At 6:30 PM medical staff made arrangements to transfer the patient to another hospital, for care by a pediatric endocrinologist. The "Emergency and Trauma Services-Physician 's Note" contains a line labeled "Disposition: Time:___". A time is not entered. A box labled "Transfer to:___" is checked and the receiving hospital is identified.

"Provider Assessment, Certification and Consent for Patient Transfer to Another Facility" has a section labeled "Transfer Requirements". The section stating the patient is to be transferred by qualified personnel and equipment is not checked. Below the statement is a line labeled "Transport Agency". "CMT" is written on this line.

The medical record does not contain a "Transfer Order Sheet" or "Interfacility Transfer Form". The medical record does not contain any other information regarding the personnel or equipment ordered for the transfer.

Medical staff failed to order the personnel (EMT, Paramedic, RN) needed to accompany the patient, and the transportation equipment (Basic or Advance Life Support ambulance, and medical equpment) needed for the transfer of the patient.

Patient #15


On 10/30/12 at 7:00 am a 28 year old patient, who was 33 weeks pregnant with twins, presented to the Labor and Delivery (L&D) unit reporting spontaneous rupture of membranes. The patient's vital signs and fetal heart rates were assessed. A routine urine sample was obtained and sent to the laboratory. The patient ' s diagnosis was premature rupture of membranes.

A "Presciber's Order Sheet", which is not dated or timed, documents a physician order to transfer the patient to a tertiary care L&D unit and administer intravenous fluids.
"Interfacility Transfer Form" section "IV. Mode/Support/Treatment During Transfer as Determined by Physician" contains a a line labeled "Mode of transport for transfer". The line contains check boxes labeled "BLS" (Basic Life Support), "ALS" (Advanced Life Support), "Helicopter" , "Neonatal Unit" and "Other". No boxes are checked.

Another line in this section is labeled "Support/Treatment During Transfer". The area below this line contains check boxes labeled "Cardiac Monitor", "Oxygen Liters___", "Pulse Oximeter", "IV Pump, "IV Fluid: ___", "Rate:___", "Restraints-Type:___" and "Other:___". No boxes are checked.

Section "V. Receiving Facility and Individual" contains a line labeled "Transferring Physician Signature" and additional lines for the date and time. All lines in this Section are blank.

Medical staff failed to order the transportation equipment (Basic or Advance Life Support ambulance, and medical equpment) needed for the transfer of the patient. Additionally, the physician failed to sign, date and time the "Interfacility Transfer Form".


Policy and Procedure

Provider policy and procedure #15-C-1, titled "EMTALA-Transfer" (effective 3/13/09) was reviewed. The policy describes how transfers will be effected. The policy states the transfer must be "...carried out through the use of qualified personnel and transportation equipment..." It also states "The sending provider shall be responsible for determining the appropriate mode, equipment and attendants for the transfer."

During the onsite survey the provider was asked for the documentation used to effect a transfer. The packet of documents provided included: "Interfacility Transfer Form" (1/06), "Provider Assessment, Certification and Consent for Patient Transfer to Another Facility" (11/09), "Transfer Order Sheet" (10/08), and "SBAR Transfer Record" (6/08). The "Interfacility Transfer Form" and "Transfer Order Sheet" both contain areas to document the specific types of personnel and equipment to effect a transfer.