HospitalInspections.org

Based on findings from document review and interview, in 4 of 6 personnel files (Staff A, B, C and D), the hospital did not ensure emergency department (ED) staff had current required training in accordance with New York Codes, Rules and Regulations (NYCRR). This lack of current training could potentially lead to inadequate care of patients presenting to the ED with a emergency medical condition.

Findings include:

-- Per NYCRR Title 10 (405.19), it requires ED staff (providers and nurses) to be currently trained in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS).

-- Per review of Staff A's (ED Medical Director) personnel file (employed since 6/1998), it lacked evidence Staff A had current training in ACLS and PALS.

-- Per review of Staff B's {Nurse Practitioner (NP)} personnel file (employed since 3/2011), it lacked evidence Staff B had current training in ACLS and PALS.

-- However, per review of the job description for ED Medical Director it did not require ACLS and PALS certification.

-- However, per review of the general job description for NPs (not specific to NPs in the ED) it did not require ACLS and PALS certification.

-- Per NYCRR Title 10 (405.19), it requires ED nurses to be currently trained in ACLS and PALS.

-- Per review of Staff C's {ED Registered Nurse (RN)} personnel file (employed since 1/2012), it lacked evidence Staff C had current training in ACLS.

-- Per review of Staff D's (RN, ED Director) personnel file (employed since 6/1983), it lacked evidence Staff D had current training in ACLS.

-- During interview of Staff E (Director of Quality Management) on 2/34/17 at 3:45 pm, he/she acknowledged the above findings.

Based on findings from document review, medical record (MR) review and interview, the hospital did not ensure emergency services were performed in a safe and consistent manner. Specifically, (1) in 1 of 5 MRs (Patient #1) reviewed, a patient (Patient #1) presented to the emergency department (ED) under an involuntary status, New York State (NYS) 9.39, 9.40 Mental Health Law (MHL) and eloped from the ED. (2) The hospital's policies and procedure (P&Ps) related to elopement in the ED did not describe a process that prevents NYS 9.39 and 9.40 MHL patients from elopement. (3) Staff lacked understanding of the requirements to prevent NYS 9.39 and 9.40 MHL patients from elopement. (4) In 3 of 5 MRs (Patients #2, #3 and #4) reviewed, patients presenting to the ED on involuntary status (NYS 9.39 and 9.40 MHL), all lacked documentation of monitoring to prevent elopement. This could place patients at risk for elopement.

Findings regarding (1) above:

-- NYS 9.39, 9.40 MHL states "Standard: reasonable cause to believe that the person has a mental illness for which immediate observation, care and treatment in a hospital or Comprehensive Psychiatric Emergency Program (C.P.E.P.) is appropriate and which is likely to result in serious harm to him/herself or others. NYS 9.41, 9.45 MHL indicates that a peace or police officer or Director of Community Services may initiate a request for 9.39 or 9.40 evaluation. A patient identified as a NYS 9.39 or 9.40 MHL is in an involuntary status. The patient cannot leave the hospital until evaluation and determination are completed.

-- Per MR review, Patient #1 (Index Pt), a 49-year-old male, presented to the ED on 10/6/16 at 11:35 am under NYS 9.45 MHL with episodes of paranoia. Patient #1 was triaged at 11:39 am as a Level 2 on the Emergency Severity Index (ESI) (1= most urgent, 5= least urgent). Vital signs and nursing assessment were completed. Patient was seen by Nurse Practitioner at 12:40 pm. "Chief complaint: psychiatric evaluation requested, sent from ... clinic for paranoia that started today. The patient is non-compliant with his medication." A physical exam was performed and included a psychiatric/neurological assessment revealing "speech normal. Cranial nerves normal (as tested). No cerebellar findings. No motor deficit. No sensory deficit. Disoriented." Laboratory tests were ordered. At 1:20 pm, nursing documented the patient left the ED without completion of treatment, patient was unaccompanied. He was alert and oriented X 4 (oriented to time, place, person and situation), coherent and in no acute distress. Unable to locate patient. The patient did not notify the ED staff prior to leaving the department. The Binghamton Police Department notified the patient eloped and has not been found.

Findings regarding (2) above:

-- Per review of the facility's P&P titled "Emergency Department (ED) Security Officer Post," last revised 4/2016, security officers posted in the ED will be responsible for maintaining patient watches on all individuals brought into the ED who pose a threat to the safety of themselves, other patients, visitors or staff members. This includes all patients brought in under NYS MHL.

-- Per review of the facility's P&P titled "Security Officer's Responsibilities in the UHS (United Health Services)- Hospitals Emergency Departments (ED)," last revised 1/2016, it indicated security staff requested to maintain a patient watch will document the following on their "Daily Activity Report" (DAR): the reason for the watch (Patient's status) and start and end time of the watch.

-- Per review of the facility's P&P titled "Emergency Department Triage," last revised 3/2014, it indicated patients triaged as a level 2 on the ESI with suicidal ideation should have closer observation, address safety concerns and elopement potential.

-- Per review of the facility's P&P titled "Elopement Precautions," last revised 3/2014, it indicated the triage nurse will do a risk assessment of the patient to determine the patients' ability to comply with instructions and that the patient must stay to have a medical screening exam (MSE) done prior to being allowed to leave. Patients presenting to the ED pursuant to the MHL and who answers "yes" to any of the safety questions, or is deemed at risk because of their lack of understanding of the situation, will be placed on elopement precautions by order of the physician or midlevel provider. Security will be notified when a patient is placed on elopement precautions and will watch the patient and attempt to have the patient comply with the decision to stay until the ED physician performs a MSE.

These P&Ps do not require that all patients under NYS 9.39 or 9.40 MHL status be monitored for elopement or describe any procedure for documenting monitoring of NYS 9.39 or 9.40 MHL patients.

Findings regarding (3) above:

-- Per interview of Staff D (ED Manager) on 3/23/17 at 12:45 pm and 4:10 pm and on 3/24/17 at 9:00 am, the physician makes the decision for monitoring patients in the ED with commitment papers (NYS 9.39 and 9.40 MHL). Not all patients awaiting or going to C.P.E.P are on elopement precautions. Patient monitoring is based on the patient's behavior. Paperwork for a NYS 9.45 MHL is only a "transport order".

-- Per interview of Staff A (ED Medical Director) on 3/23/17 at 1:00 pm, after psychiatric patients with commitment papers are triaged, a medical exam is performed to evaluate the need for medical intervention. Depending on the psychiatric complaint the provider determines if the patient needs a C.P.E.P evaluation or inpatient care. Monitoring psychiatric patients in the ED depends on the patient's complaint and risks as to how closely they'll be watched.

-- Per interview of Staff F (Security Supervisor) on 3/23/17 at 1:55 pm, the physician makes the decision for monitoring patients with commitment papers. One security officer is dedicated to the ED to make sure staff and patients are safe.

-- Per interview of Staff C (RN who provided care to Patient #1) on 3/23/17 at 2:25 pm, patients presenting to the ED with commitment papers are usually an automatic flag to alert providers that an elopement precaution order should be entered in the medical record. Security may be notified verbally if an elopement precaution order is entered. This order informs security to do a security check to make sure the patient doesn't have anything dangerous on themselves and they try to keep an eye on the patient, however, they could be watching several other patients at the same time.

-- Per interview of Staff H (Security officer) on 3/23/17 at 2:45 pm, patients with commitment papers arriving to the ED via ambulance are taken directly to a room, nursing triages the patient and then security sees the patient. Security receives prior notification that the patient is coming to the ED through ambulance dispatch. The provider or nurse (takes a verbal order from the provider) orders the elopement precaution. The elopement precaution order is an order for patients we want to make sure don't leave. After security completes the inventory checklist (patient belongings) they are to monitor (have a visual) of the patient. Security may have several patients to watch at one time. Security documents the time the patient came in and the patient's activities every 30 minutes on security's "Daily Activity Report" (DAR).

-- Per interview of Staff H (RN who triaged Patient #1) on 3/24/17 at 10:15 am, he/she informs the physician of a patient with NYS 9.45 MHL paperwork. If the patient is suicidal or homicidal the patient is put on elopement precautions. A patient that is alert and oriented and not suicidal or homicidal, he/she sometimes does and sometimes doesn't request a patient have an elopement precautions order, it's based on the patient's presentation and clinical assessment. Security needs an order for elopement precautions.

Staff interviews indicated that staff and providers did not have a understanding of monitoring requirements of NYS 9.39 and 9.40 MHL patients.

Findings regarding (4) above:

-- Per MR review of Patient #2, he presented to the ED on 10/2/16 at 8:17 am under NYS 9.41 MHL with delusional, paranoid, auditory hallucinations and bizarre behavior. The MR lacked documentation that the patient was monitored for elopement in the ED.

-- Per MR review of Patient #3, he presented to the ED on 10/6/16 at 4:58 pm under NYS 9.41 MHL with depression and suicidal thoughts. The MR lacked documentation that the patient was monitored for elopement in the ED.

-- Per MR review of Patient #4, she presented to the ED on 10/1/16 at 1:13 pm under NYS 9.41 MHL with depression and request for psychiatric evaluation. A self-harm assessment was positive. The MR lacked documentation that the patient was monitored for elopement in the ED.

-- During interview of Staff D (ED Manager) on 3/24/17 at 1:50 pm, he/she acknowledged the above findings.