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Based on observations and staff interviews, it was noted that the facility failed to consistently post written notification in all required locations which advise patients about the right to emergency medical screening and treatment in accordance with the Emergency Medical Treatment & Labor Act (EMTALA) regulations.

Findings include:

During tour of the facility ' s Emergency Department on 1/27/14 between the hours of 11:45 AM and 1:30 PM, written notices were not conspicuously posted in all required areas of the emergency room which specify the rights of patients in accordance with Section 1867 of the Act related to examination and treatment of emergency medical conditions and women in labor (EMTALA).

Two EMTALA signs were posted on a wall adjacent to triage booth #1 and across from the nursing station located between ED treatment sections ED-1 and ED-2. These signs were posted in English and Spanish on 8 ½ " by 11 " inch paper in print using an approximate 12 point font. The posters were not plainly visible and could be overlooked by patients and visitors. The letters within the signs were not clearly readable at a distance of at least 20 feet or from the viewpoint of the emergency department clients.

No signs were posted in the adult or pediatric waiting room seating areas, emergency room treatment section ED-2 , treatment section ED-1, pediatric emergency treatment area, and psychiatry emergency section (" ED-3 ").

During interview with Staff #1 and Staff #14 on 1/27/14, the staff acknowledged the print on the signs was too small to read.
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Based on interviews and review of documents, video recording, and procedures, it was determined the facility failed to implement effective practices to monitor the emergency waiting room for patients with presumptive medical needs to ensure that all patients receive medical screening examination. There was no medical screening examination noted in 2 of 66 emergency medical records reviewed. (MR #1 and MR#2)


Findings include:

The facility failed to provide medical screening to 2 of 66 patients who arrived to the hospital's emergency room for emergency medical needs.

1. Review of MR#1 on 1/27/14 at 11 AM makes specific reference to an event which occurred on 1/20/14 in which a male patient was found by Security staff to be in cardiac arrest in the waiting room, approximately eight hours after triage. The patient was in a position where his face was between his knees seated in a chair in the rear section of the emergency waiting room.

Review of MR #1 on 1/27/14 at 11 am found this 30 year old male presented for emergency care as a walk in on 1/19/14 at 9:52 PM. The patient 's pre-triage assessment was conducted at 9:52 PM (where a face to face encounter occurs where the registered nurse speaks with the patient through a glass window). The written encounter form documented during this "quick registration " process noted the patient's reason for visit as "left hand has abscess" .

Formal triage was provided at 10:04 PM on 1/19/14, and the electronic triage form notes patient the complained of itch on the arms for four days. Vitals were taken and documented a: temperature of 98.7 F, respiratory rate of 18, BP (Blood Pressure) of 121/68, SPO2% 100% on room air. No pulse was noted in the triage assessment. The pain scale was rated as 4/10 in the extremities, constant, with tightness.

Past medical history noted was significant for "asthma/ COPD (chronic obstructive pulmonary disease), hepatitis , osteomyelitis". He was classified as Emergency Severity Index triage level =3 , which is classified as an urgent category. This represents conditions that could potentially progress to serious problems requiring emergency intervention.
The patient was registered at 9:54 PM.

At 12:55 AM on 1/20/14 the physician noted in the record: "patient was called overhead with no response. Patient looked for in the ED waiting area with no response. Patient not found in ED beds, asthma area: patient not in ED at this time."

At 3:10 AM the physician documented in the record: "patient was called overhead with no response. Patient looked for in the ED waiting area with no response. Patient not found in ED beds, asthma area: patient not in ED at this time." (Note this is the same text used in the previous note in the medical record.

Interview with staff #4 on 1/28/14 reported he called the patient's name from the emergency department (ED) door).

At 4:08 AM, the physician noted in the record that "the patient was called overhead in the waiting area and in the Emergency Department. The patient did not respond and cannot be located at this time."

The patient was later found unresponsive in the ED waiting room at approximately 6:42 AM. A new emergency department record of encounter was created at this time.(6:44 AM)

The patient was found with no vital signs, slumped over and cyanotic. He was immediately transported into the ED treatment area and resuscitation attempts /CPR were unsuccessful. Patient was pronounced dead at 6:55 AM on 1/20/14. Review of the cardiac arrest record by the physician found the patient was found in the ED waiting room, unresponsive, with facial cyanosis. There was never any pulse found and the cardiac monitor registered asystole, refractory to all interventions, including endotracheal intubation, 3 rounds of epinephrine, bicarb x 2, 2 administration of glucose, and one of Narcan. Patient was pronounced dead at 6:55 AM on 1/20/14 and sent to ME.

Videotape monitoring of the emergency department waiting room was viewed with hospital staff (Staff #1, #2, #13, #22) on 1/28/14 between the approximate hours of 1:50 PM and and 3:20 PM.

The videotapes showed the chronology between the patient's arrival on 1/19/14 at 9:38 PM for triage until and the time he was found to be in cardiac arrest by a security officer on 1/20/14 at 6:37 AM, while the officer performed rounds in the emergency waiting room to clear the waiting room of sleeping persons. The videotape record shows that between 10:31 PM on 1/19/14 and 6:37 AM on 1/20/14, the patient was in a position where he was bent over and where his head was between his knees. (slightly greater than a period of eight hours).


Review of security incident situation reports (4) on 1/20/14 documented at 0647 AM and one incident report form ( MD documented at 0715 am and nurse documented at 6:40 AM) were reviewed on 1/27/14.

Security report #1 written by one security officer states that he and another officer went to the waiting area at 640 AM to clear the area. This officer further writes that he was getting everyone up who was sleeping and went to the patient in MR #1 to try to wake him up. The patient did not respond. This officer wrote he lifted patient.

Review of form titled " Patient and Visitor Incident report" form dated 1/20/14, included a physician report , timed at 0715 AM stated " patient was found slumped in cardiac arrest in the waiting area of the ER. The patient was wheeled to the main ER. CPR, ACLS, intubation, and left femoral line were done. Patient was not responsive and pronounced dead at 0655 AM."


Interview with staff # 4 on 1/28/14 at 3:30 PM was conducted, who was assigned to the patient during the ED visit of 1/19/14. Staff #4 stated he called the patient's around 1 am on 1/20/14. He called overhead and went to the ED waiting room door to call the patient by name. He waited 2 minutes and there was no answer. Inside the ED, usually he does a quick sweep through ED-2 (the area where patients are inside of the ED treatment area on a stretcher remain). At 3 AM he did the same thing and there was no answer by the patient. He acknowledged he does not go directly into the ED waiting room to call patients.

Staff #4 also reported he received a call on 1/20/14 for a stretcher in the waiting room, the patient looked dead. The patient's face was blue. The patient was placed on a stretcher and wheeled to ED-1 and ACLS was started. He spent the whole time doing compressions. The attending physician pronounced the patient dead.

On 1/28/14 at 3:30 PM surveyors interviewed staff #5, who stated he called the patient at least once overhead on the loudspeaker and then he went to the ED door where there was no answer/response. He reported that during overnights, the ED receives a lot of patients where a no answer is very common. When queried if he goes into the waiting room area to call patients he replied "generally no".
He recalled that during this incident, one patient care technician (PCT) ran into the ED and reported the someone out there looks blue. He went to ED-1 (section of the medical emergency room) , prepared beds for a code. He followed standard ACLS protocol . A Central line placed in the groin. The patient's face was blue.

The two triage nurses, staff #6 and Staff #7 were both interviewed concurrently on 1/29/14 at 8:30 AM. The initial pre-triage encounter slip was signed by staff #7 at 9:52 on 1/19/14, who reported at interview that she did not recall the patient at all.

The process for initial screening was described by staff #7. The walk in patient comes to the glass triage booth, and if able to do so, the patient shall document the name , date of birth, and reason for visit in the ED. The nurse speaks with the patient through the window. The nurse does not come outside of the booth to fully visualize patients. The patient then takes this slip to the registration clerk. If the patient is very ill, the patient is brought directly inside of the ED.

After initial screening, the patient shall wait in the waiting room for full triage. Staff #7 performed the full assessment on patient referenced in MR #1. The patient said he had a rash. The patient had splotches to both arms. He did not see the patient after triage. He stated that rounds are never done by the nurse of the waiting room.

Staff #6 was queried if he noticed that the encounter slip noted the patient had a left hand abscess, which differed from his note which documented arm itching/rash. He stated that registration actually holds on to the form and the clerk inputs the complaint .

Both staff #6 and #7 stated that they never look into the waiting room to monitor patients.

The policy titled, "Triage of patients Adults and Pediatrics" was reviewed on 1/28/14 at 10 AM. The facility's ED policy for triage of Patients in effect at the time of the incident notes: "The triage nurse will monitor the waiting area". No guidance or instructions are documented to explain how this waiting room monitoring shall occur from the time of the patient arrival, through triage, and until the call for medical evaluation.

Review of ED Procedures on 1/28/14 finds that the emergency department (ED) has no policy and procedure for marking charts as no answer in the walk in waiting room. Furthermore, there is no policy to address patients who do not answer prior to the completion of full triage nor for those patients who do not answer to staff and/or who leave after complete triage (prior to performance of a medical screening examination).
Additionally, the facility has no policy and procedure for the reassessment of patients who are triaged to the waiting room.

In addition the triage policies require that patients triaged as ESI-3 , which was the category assigned to the patient referenced in MR#1, are to have vital signs taken no less frequently than every two hours for the first four hours then every four hours if clinically stable. The patient was classified as Emergency Severity Index triage level =3 , which is classified as an urgent category. This represents conditions that could potentially progress to serious problems requiring emergency intervention. In the case of MR #1, the patient failed to follow this process, because MR #1 had been triaged as ESI-3 and should have had vital signs within 2 hours of triage. However, based on interview with staff #2 on 1/28/14, it was stated there is no written schedule for reassessment for patients triaged to the waiting room.

Despite having been triaged as level three, the patient never received a medical evaluation and the staff's attempts to locate this patient were insufficient.

The facility failed to effectively monitor the emergency room waiting area to ensure the health and safety of patients awaiting medical evaluation or for those with presumptive need for medical care.

The facility failed to provide a medical screening examination to a patient who was triaged but who did not answer calls made by medical staff for a medical screening examination. The facility failed to implement a process for emergency waiting room patients who are unregistered or who do not respond to calls for medical evaluation following triage.

2. Review of MR #2 on 1/29/14 at approximately 3 PM referenced a pregnant patient who came by EMS who complained of generalized body aches was never triaged and thus never received any medical screening examination.

Review of MR #2 found that on the ambulance call report (ACR) that the patient arrived at 12:32 PM on 1/27/14 complaining of body aches and the ambulance call report was signed by the Emergency department triage nurse.

During interview with the triage nurse in the adult ED (staff #23) on 1/29/14 at approximately 2 PM, the nurse stated that she signed the ACR and she sent the patient and EMS to Labor and Delivery for triage and assessment. The nurse stated she did not triage the patient nor take any vital signs.

During interview with the Staff #12 on 1/31/14, Staff #12 stated that there was no record of the patient being examined, no record of fetal monitoring performed, no chart was prepared , and the patient was sent back to the main ED because the patient's complaints were not related to pregnancy.

Review of the triage log book for Labor and Delivery on 1/31/14 for the date of 1/27/14 at 1341 hours (1:41 PM) found that the patient was transferred to ED.

The patient was returned to the ED where she walked out without being triaged or medically evaluated.

Review of policy and procedure titled : "Pregnant patients presenting to the ED" on 1/31/14 it is stated that pregnant patients presenting to ED with pregnancy greater than 20 weeks whose complaint is non-pregnancy related , e.g., asthma, shall be registered in the ED and be evaluated by the emergency physician. Further review of policy finds that pregnant patients with flu like illness are to be isolated away from the maternity pavilion. In the case of MR #2 staff failed to follow this policy.
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Based on review of records, transfer procedures , and staff interview, it was determined the facility's process did not include a specific requirement to document that patients or their representatives have been counseled about the specific risks and benefits of transfer to another facility from the emergency room for stabilizing care; This finding is noted in 17 of 17 emergency transfer records reviewed. ( MR #s 6, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25)

Finding include:

The Emergency Department form for "Consent to transfer", "Transfer Information" and adult and pediatric procedures for "Transfers- Inter-institutional" , T.06 and T.005, were reviewed on 1/30/14. Both procedures require the patient, parent, relative, and /or legal guardian to sign consent and that the reasons for transfer are explained. However , these lack a clause to document that the specific risks and benefits of transfer are explained and procedures do not require these individualized risks/benefits be listed on pertinent transfer consent forms or medical attestation forms.

The form for consent to transfer notes pre-formatted language which may be checked by the medical provider which includes:
"In my medical opinion, this patient's condition has not been fully stabilized, but the benefits of transfer outweigh the risks, because the patient requires specialized care not available at St. Barnabas but available at the receiving institution". Side 2 of this form summarizes the physician's attestation for diagnosed condition and objective results.

The forms do not include a clause in which the physician describes that the risks and benefits were explained to the patient or person consenting for transfer and does not list the specific risks of transfer for the patient. The certification form must contain a summary of the risks and benefits upon which transfer is based.

Example:

MR#10:
The record for this 3 month old infant was reviewed on 1/29/14. The child was found by the mother on 8/11/13 to be unresponsive and not breathing at home and resuscitation was underway with ambulance staff prior to arrival in the emergency room. Baby was intubated and treated for cardiac arrest. The child was transferred to another hospital for further management.

Review of consent to transfer form found the section noting reason for the transfer was not checked; the reason was unexplained to the mother. The physician checked the clause that the benefits of transfer outweigh the risks but failed to list the specific risks of transfer nor that these risks were explained to the parent. The certification form, titled, " New York State Department of Health Emergency Medical Services Development Program Transfer information", did not contain a summary of the risks and benefits upon which it is based.

MR #6: The record for this 15 year old male was reviewed on 1/30/14. Patient was held for assessment of suicidal and homicidal ideation in the adolescent psychiatric holding area where it was determined he was experiencing major depression with psychotic features . He remained in the holding area of the ED for six days until he was transferred to another facility for inpatient psychiatric care on 1/29/14.
The patient 's consent to transfer indicated the reason for transfer on the checklist as no available beds in the hospital. This form was signed by the representative but the staff failed to check one of the three options on the checklist regarding whether or not the patient was stabilized. The form titled, " New York State Department of Health Emergency Medical Services Development Program Transfer information", noted the diagnosis, and the name of the physician and hospital accepting the patient. Neither form listed a summary of the individualized risks and benefits for transfer, nor that it was explained to the representative.

MR #24: The record for this patient was reviewed on 1/29/14. This patient was a 19 year old male who was a trauma code in the pediatric ED on 8/2/13. The patient was transferred for neurosurgery at another acute care hospital because there was no available bed in the pediatric intensive care unit (PICU). The record did not include the specific risks of transfer and complications.


Similar findings were identified in records for transferred patients from the emergency room in that the forms in use do not contain a section to list the specific risks of transfer nor document that the transfer risks are explained to the patient or the representative. Refer also to MR#s 6, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25.
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