HospitalInspections.org

Based on observation, staff interview and document review, it was determined that the hospital failed to have an effective governing body.

Findings include:

The Governing Body failed to provide the necessary oversight and leadership as evidenced by the facility's lack of compliance with the Medicare Conditions of Participation for hospitals, specifically:

42 CFR 482.13 Patient Rights
42 CFR 482.30 Utilization Review

Based on observation, medical record review and staff interview, it was determined that the facility failed to protect and promote each patient's rights.

Findings include:

1. The facility failed to comply with Suicide prevention precautions on the Psychiatric Unit. (Refer to Tag 0144.)

2. The facility failed to ensure patient safety while patients are being restrained. (Refer to Tags 0144, 0160, 0168 and 0175.)

A. Based on observations during a tour of the Psychiatric Unit on April 30, 2012, in the presence of Staff #3 and 46, it was determined that the facility failed to ensure that all patients receive care in a safe setting.

Findings include:

1. The Psychiatric Unit failed to comply with suicide prevention based on the following:

a. The sink faucets in all patient room bathrooms could support a patient's weight in a suicide attempt.

b. The pipes under the sink and the toilet supply pipes in all patient bathrooms were exposed, which could allow for insertion of an object and support a patient's weight in a suicide attempt.

c. All patient bathroom doors and the upper clothing cabinet doors in the patient rooms have a gap between the frame and the door which could allow for insertion of an object and support a patient's weight in a suicide attempt.

d. Screws which were not tamper proof were located at the wall posters and at the wall mounted medical gas outlet covers on the walls in the patient rooms.

e. In all patient rooms 4" by 4" flaps/lids on top of the radiators were not secured. Lids are easily opened, exposing pipes which could allow for insertion of an object and support a patient's weight in a suicide attempt.

f. In 6 of 7 double-bedded rooms, the beds are regular hospital beds that can support a patient's weight in a suicide attempt and contained electrical cords that could be used in a suicide attempt.

g. In Room 564 the thermostat cover was broken, exposing wires and parts.


B. Based on medical record review and review of policies and procedures it was determined that the facility failed to ensure that all patients receive care in a safe setting.

Findings include:

1. In Medical Record #12 the nurses' notes indicated that the patient had been in 4 point locked restraints on 3/26/12 at 7:30 AM. From 9:00 AM until 7:00 PM on 3/26/12 the patient had a right ankle restraint. This type of restraint (one limb restraint) could potentially cause serious injury if the patient attempted to get out of bed.

Reference: Facility "Leaving Against Medical Advice and Elopement" policy stated, 'Procedure: For patients requesting to leave against medical advice: ... 4. Where a patient lacks decision making capacity, the request to leave against medical advice must be made by the patient's legally authorized representative and the care team will counsel that person on the risks of leaving and obtain that person's signature on the Release of Liability form. Where the care team believes that the representative's decision to have the patient leave creates a substantial risk of serious injury to the patient, Risk Management or, if applicable, the Vice President on Call shall be contacted."

2. As per Medical Record #12 the patient was physically and chemically restrained on the afternoon of 3/23/12 following refusal to have an abscess drained. The patient became agitated, abusive and wanted to leave AMA. The psychiatric note indicated at 1:43 PM that "...in my opinion this patient lacks the capacity to make this medical decision to leave AMA without treatment... 1. If the patient has a health care proxy, the agent should be contacted. 2. If there is no health care proxy, effort should be made to identify an appropriate substitute decision maker ... it may be necessary to have a guardian appointed ...3. In the case of a true emergency, treatment may be provided without consent, but should be discussed with the Office of General Counsel as soon as possible."

a. There was no evidence in Medical Record #12 of family members' information or a health care proxy. There was no evidence in Medical Record #12 that the Office of General Counsel was contacted to discuss emergency treatement of this patient who in the psychiatrist's opinion lacked the capacity to make decisions.


14153

C. Based on a tour of operating rooms (OR) at the Voorhees Surgical Center and staff interview, it was determined that the facility failed to ensure that all patients receive care in a safe setting.

Findings include:

1. During a tour of OR #2 and 4 at approximately 10:30 AM on 5/3/12, in the presence of Staff #37, the following was observed:

a. The paint was peeled and chipped at the window in OR #2.

b. The paint was peeled and chipped at the window in OR #4.

c. The above findings were confirmed by Staff #37.

Based on medical record review and review of facility policies and procedures, it was determined that the facility failed to ensure that the Restraints/Seclusion policy was implemented.

Findings include:

Reference: Facility "Restraints/Seclusion" policy states, "Definitions: ... 3. A chemical restraint is a medication used to restrict the patient's freedom of movement that is not a standard treatment for the patient's medical or psychiatric condition. Since it is the policy of Cooper University Hospital only to use medications that are indicated to treat the patient's ongoing or newly emerging condition, chemical restraint should not be used for restraint purposes."

1. In Medical Record #12, the physician's note dated 3/23/12 at 4:00 states, "After team unable to obtain voluntary consent for drainage due to poor capacity and patient became agitated, verbally abusive, and requested to sign AMA [against medical advice], larger team assembled to effectuate safe physical and chemical restraint to effectuate optimal medical management. After team assembled including..., patient physically then chemically restrained..." The patient was placed in 4 point restraints and given 15 mg (milligrams) of Haldol IV (intravenously) and 5 mg of Haldol IM (intramuscularly), restricting the patient's freedom of movement.

2. The facility failed to ensure compliance with the above policy, "Restraints/Seclusion."

Based on medical record review, it was determined that the facility failed to ensure that patients are restrained in accordance with the order of a physician.
Findings include:
1. Medical Record #12 revealed the following:

a. The orders dated 3/24/12 at 10:55 PM and 3/25/12 at 4:38 AM stated, "4 Point Locked, Four Hour Restraints." The nurse's flowsheet on 3/24/12 lacked evidence that the patient was in 4 point locked restraints from 10:55 PM until 7:59 AM on 3/25/12. There was no evidence that the order for restraints was discontinued or that the patient met criteria for removal of the restraints.

b. The nurse's flowsheet indicated that the patient was in 4 point locked restraints from 8:38 AM on 3/25/12 until 11:32 AM without a valid physician order.

c. The nurse's flowsheet indicated that the patient was in 4 point locked restraints on 3/25/12 from 4:50 PM until 11:35 PM without a valid order.

d. The nurse's flowsheet indicated that the patient was in 4 point locked restraints on 3/26/12 from 3:35 AM until 8:40 AM without a valid order.

e. The orders dated 3/26/12 state:

9:55 AM, "4 Point Locked, Four Hour Restraints."
3:57 PM, "4 Point Locked, Four Hour Restraints."
6:46 PM, "4 Point Locked, Four Hour Restraints."

i. The nurse's flowsheet on 3/26/12 indicated that only the patient's right ankle was in restraint from 9:00 AM until 7:00 PM. At 7:00 PM the right ankle restraint was discontinued. The physician orders for 4 point restraints were not implemented.

ii. The nurse's flowsheet indicated that the patient was in restraints on 3/26/12 from 1:55 PM to 3:57 PM without a valid physician order.

f. The order dated 3/27/12 at 3:10 PM, states, "4 Point Locked, Four Hour Restraints."

i. The nurse's flowsheet indicated that the patient was not in 4 point locked restraints on 3/27/12 at the time of the order. The nurse's flowsheet indicated that patient was out of restraints on 3/26/12 at 7:00 PM, when he/she met criteria for restraints removal. There was no evidence that the nurse communicated with the physician regarding the implementation or discontinuation of the above order.

A. Based on review of medical records and facility policy and procedure, it was determined that the facility failed to ensure that the condition of the patients are monitored by a competent staff member every 15 minutes, as required by facility policy.

Findings include:

Reference: The 'Violent/Self Destructive Restraint and Seclusion {All Units}' section of facility policy titled 'Restraints/Seclusion' states, "6. Observation/monitoring: a. Patients in restraints or seclusion will be observed/monitored continuously in-person by a competent staff member and shall assess the patient at the initiation of restraint or seclusion and every 15 minutes thereafter...
b. The Interventions and assessments shall include the following,
- Signs of any injury associated with applying restraint or seclusion
- Nutrition and hydration
- Circulation and range of motion in the extremities
- Hygiene and elimination
- Physical and psychological status and comfort
- Ambulation at least once every four hours if clinically feasible
- Assistance with bathing as required occurring at least once a day..."

1. Review of Medical Record #12 indicates that the patient was in 4 point restraints on 3/24/12 at 8:00 PM until 8:00 AM on 3/25/12. There was no evidence on the 15 Minute Flowsheet form or in the nurse's documentation that fluids or food were offered during the 12 hours the patient was in restraints.

2. The restraint flowsheet, dated 3/25/12 from 7:00 AM to 3:00 PM, lacked evidence of the patient being monitored by staff every 15 minutes.

3. The facility failed to ensure compliance with Policies and Procedures.



20148



4. Review of Medical Records #32, #33 and #34 indicates that each patient was restrained for violent and/or self destructive behavior. There was no evidence in these medical records that the patients were assessed and that interventions based on the assessments were implemented in accordance with the above referenced policy.

5. The above findings were confirmed by Staff #1 on 5/2/12 at 11:00 AM.

Based on review of 2 post operative medical records, review of the Medical Staff Rules and Regulations, and staff interview, it was determined that the facility failed to ensure that the Medical Staff Rules and Regulations were enforced.

Findings include:

Reference: "Rules and Regulations of the Medical Staff of Cooper University Hospital" states: General Conduct of Care, Section: C. The practitioner's orders must be written or entered clearly, legible and completely...use of "PRN" medication order should be qualified.

1. Medical Record #3 contained the following orders:

a. Dilaudid 50 mg/ml (milligrams/milliliter) Normal Saline (NS) Patient Controlled Analgesia (PCA). Dose: 0.2 mg, delay: 10 minutes, hour limit: 1.2 mg/hr. Start date and time 4/30/12, 3:45 AM.

b. Dilaudid 0.5 mg, every 15 minutes PRN (as needed), Intravenous (IV), maximum dose 2 mg. Indication: Mild pain. Start date and time 4/30/12, 3:19 AM.

c. Motrin 600 mg tablet, route; oral, every 6 hours PRN. Indication: fever. Indication: Moderate pain. Start date and time 4/30/12, 3:19 AM.

d. Toradol 30 mg IV, every 6 hours PRN. Indication: Moderate pain. Start date and time 4/30/12, 3:23 AM.

e. Oxycodone 10 mg tablet, route: oral, every 4 hours PRN. Indication: Severe pain. Start date and time 4/30/12, 3:20 AM.

f. Oxycodone 5 mg tablet, route: oral, every 4 hours PRN. Indication: Moderate pain. Start date and time 4/30/12, 3:19 AM.

g. Tylenol 325 mg tablet, route: oral, every 4 hours PRN. Indication: Moderate pain. Start date and time 4/30/12, 3:19 AM.

h. Tylenol 325 mg 2 tablets, route: oral, every 4 hours PRN. Indication: Fever, mild pain. Start date and time 4/30/12, 3:19 AM.

i. There are no clear parameters indicating which PRN medication should be administered for pain.

2. Medical Record # 5 contained the following orders:

a. Motrin 600 mg tablet, route; oral, every 6 hours PRN. Indication: Fever, Moderate pain. Start date and time 4/29/12, 12:05 PM.

b. Toradol 30 mg, IV, every 6 hours PRN. Indication: Moderate pain. Start date and time 4/29/12, 12:06 PM.

c. Tylenol 325 mg tablet, route: oral, every 4 hours PRN. Indication: Fever, mild pain. Start date and time 4/29/12, 12:05 PM.

d. Tylenol 325 mg 2 tablets, route: oral, every 4 hours PRN. Indication: Fever, mild pain. Start date and time 4/29/12, 12:05 PM.

e. Oxycodone 10 mg tablet, route: oral, every 4 hours PRN. Indication: Severe pain. Start date and time 4/29/12, 12:06 PM.

f. Oxycodone 5 mg tablet, route: oral, every 4 hours PRN. Indication: Moderate pain. Start date and time 4/29/12, 12:05 PM.

g. There are no clear parameters indicating which PRN medication should be administered for pain.

3. Staff #31 confirmed the above findings.

Based on observation, document review and staff interview, it was determined that the registered nurse failed to screen patients for nutritional risk.

Findings include:

Reference 1: The Nursing Policy titled "Assessments/Reassessments of Inpatients" states "Responsible: RN," "Policy: The initial assessment shall begin at the time of admission to the hospital as clinical staff begins to collect relevant information from the patient. That information shall include,....nutritional ...screening." The "Responsibilities" section states, "A completed admission database shall be recorded by a Registered Nurse within 24 hours of admission to the hospital."

1. On 5/1/12 in the presence of Staff #16 and Staff #3, two of three (MR#13 and 15) medical records reviewed lacked a completed nutrition screening on the admission database.

a. During a review of Medical Record #13, on 5/1/12 at 10:35 AM, Staff #16 and #3 could not provide any written documentation of screening for nutrition risk on the admission database completed by the RN and dated 4/5/12.

b. During a review of Medical Record #15, on 5/1/12 at 11:45 AM, Staff #16 and 3 could not provide any written documentation of screening for nutrition risk on the admission database completed by the RN and dated 3/22/12.

2. All the above findings were confirmed by Staff #16 and 3 on 5/1/12 at 12:15 PM.

Based on observation, document review and staff interview, it was determined that the facility failed to ensure that drugs were controlled and distributed in accordance with facility policy and applicable standards of practice.

Findings include:

1. On 5/1/12, from 11:00 AM to 12:30 PM, the contents of patients' medication cassette drawers were compared with the medication administration record. In 4 of 7 medication cassettes reviewed (Patient #4, #25, #26, and #27), extra doses of medications were found. In each instance pharmacy records indicated that an extra dose of medication had been dispensed because the nurse had reported the medication as "missing."

a. Upon interview Staff #31 stated that missing medications is a problem. He/she stated that nursing staff often report missing medications that are later found in the patient's medication cassette drawer.

b. Upon interview Staff #31 stated, that although missing medications were problematic, the facility is currently not tracking the problem in a manner that would help them address and resolve it.

2. Medical Record #23 contained an order, dated 5/1/12 at 1:12:46, written when the patient was in the Emergency Department, for "ED to Go, #2 Oxycodone IR 5 mg (milligram)Tabs, orally as needed for pain." This is a Schedule II Controlled Dangerous Substance. The medication was removed from the drug dispensing device at 1:30 PM by Staff #8. Upon interview at 2:20 PM, Staff #8 stated that he/she had removed the medication and given it to the physician who then gave the medication to the patient upon discharge.

a. Upon interview at 2:30 PM, Staff #31 stated that the facility does not have a policy that allows the physician to dispense medications for the patient to take with them upon discharge.

Based on a tour of the Helipad Resuscitation Area (HRA) and staff interview on 4/30/12, it was determined that the facility failed to ensure that outdated medications were not available for patient use.

Findings include:

1. Two 1000 ml (milliliter)bags of Lactated Ringers solution dated 3/18, two 1000 ml bags of Lactated Ringers solution dated 3/19, two 1000 ml bags of 0.9% Normal Saline solution dated 3/18 and two 1000 ml bags of 0.9% Normal Saline solution, one dated 3/19 and the other not dated, were found out of the outer wrap and available for patient use,hanging on IV (intravenous) poles above two bays in the HRA.

2. During an interview, Staff #1 stated that IV solutions are to be labeled and dated when the over wrap is removed. The solutions are good for 30 days and are to be discarded after the expiration date.

Based on staff interview and document review conducted in the presence of Staff #2 and 16, it was determined that the Director of Food and Nutrition failed to ensure that daily supervision of the Food and Nutrition Services Department was provided.

Findings include:

Reference #1: The Director of Food and Nutrition job description states, "Directs and administrates all functions and services of the Food & Nutrition Services Department, following hospital policies and procedures."

Reference #2: The Food and Nutrition Services "Follow up Charting on Nutritional Care" policy states: "The dietitian or authorized person is responsible for charting on-going nutritional assessments and progress based on the patients' Level of Care."

Reference #3: The Food and Nutrition Services Attachment "Level of Care" states: "Level Four...Follow Up Nutritional Care" - documentation every 3-5 days in medical record progress notes..."

1. On 5/1/12 in the presence of Staff #16 and Staff #3, three of three "Level Four Follow Up" notes contained in Medical Records #13, 14, and 15 were not documented every 3-5 days as required in references #2 and 3.

a. On 5/1/12 at 10:35 AM, in the presence of Staff #16 and 3, Medical Record #13 contained an initial nutrition assessment signed by the RD and dated 4/5/12. The RD assessed the patient as a Level 4. The next nutrition follow-up assessments were dated 4/12/12, 4/19/12, and 4/27/12. The nutrition follow up assessments were completed every 6-7 days, and not completed in 3-5 days as stated in References #2 and 3.

b. On 5/1/12 at 11:05 AM, in the presence of Staff #16 and 3, Medical Record #14 contained an initial nutrition assessment signed by the RD and dated 4/20/12. The RD assessed the patient as a Level 4. The next nutrition follow up assessments were dated 4/26/12. The nutrition follow-up assessment was completed in 6 days, and not completed in 3-5 days as stated in References #2 and 3.

c. On 5/1/12 at 11:45 AM, in the presence of Staff #16 and Staff #3, Medical Record #15 contained an initial nutrition assessment signed by the RD and dated 3/26/12. The RD assessed the patient as a Level 4. The next nutrition follow-up assessments were dated 4/2/12, 4/5/12, 4/13/12, 4/19/12, and 5/1/12. Four of the five nutrition follow up assessments were completed every 6-12 days, and not completed in 3-5 days as stated in References #2 and 3.

3. All the above findings were confirmed by Staff #16 and 3 on 5/1/12 at 12:15 PM.

Based on observation, document review and staff interview, it was determined that the facility failed to have in effect, a utilization review plan that provides for an independent review of services furnished by the institution and members of the medical staff to patients.

Findings include:

1. The Utilization Review (UR) Committee failed to meet and carry out the UR function. Refer to Tag 0654.

2. The Utilization Review (UR) Committee failed to review professional services provided, to determine medical necessity and to promote the most efficient use of available health facilities and services. Refer to Tag 0658.

Based on observation, document review and staff interview, it was determined that the Utilization Review (UR) Committee failed to carry out the UR function and meet and conduct independent reviews of patient admission and discharge status.

Findings include:

Reference #1: The Medical Staff Organization and Functions Manual, revised September 22, 2011, states "The Utilization Review Committee will meet monthly and more frequently if deemed necessary by the Chairman (Physician Advisor)."

Reference #2: The Utilization Review Plan, dated January 2011, states, "At the end of the fiscal year, the Utilization Review Committee will have summarized in writing the year's committee activities. The Chairperson of the Utilization Review Committee shall review the report and present it to the Quality Committee of the Board."

1. On 5/1/12 at 2:00 PM, Staff #21 was asked to provide for review the UR Committee Plan and all the UR Committee meeting minutes from January, 2011 to the most recent.

a. On 5/1/12 at 2:45 PM, Staff #21 provided for review UR Committee meeting minutes dated March 30, 2011, May 5, 2011 and June 15, 2011.

b. On 5/1/12 at 2:45 PM, Staff #21 stated that the UR Committee has not met since the meeting on June 15, 2011.

c. On 5/1/12 at 2:45 PM, Staff #21 confirmed that the UR Committee did not meet monthly as stated in the Medical Staff Organization and Functions Manual, Reference # 1.

2. On 5/1/12 at 2:00 PM, Staff #21 was asked to provide for review the 2011 fiscal year end UR Committee report presented to the Quality Committee of the Board.

a. On 5/1/12 at 2:45 PM, Staff #21 did not provide for review the fiscal year end UR Committee report presented to the Quality Committee of the Board.

b. On 5/1/12 at 2:45 PM, Staff #21 stated that the UR committee report was not available since the former Chairman of the UR Committee resigned from the hospital staff during the summer of 2011.

3. On 5/1/12 at 2:00 PM, Staff #21 stated that all patients' admission and discharge status is reviewed by the case managers during the unit specific "Complex Discharge Rounds."

a. On 5/1/12 at 2:00 PM, Staff 21 confirmed that the Complex Discharge Committee consists of the unit staff and physicians providing care to the patient.

b. On 5/1/12 at 2:00 PM, Staff # 21 confirmed that "Complex Discharge Rounds" are not reviewed by an independent physician who is not involved in the care of the patient whose case is being reviewed.

c. On 5/1/12 at 2:00 PM, Staff #21 confirmed that "Complex Discharge Rounds" are not reviewed by the UR Committee.

4. All the above was confirmed by Staff #21 on 5/1/12 at 2:45 PM.

Based on observation, document review, and staff interview, it was determined that the Utilization Review (UR) Committee failed to review professional services provided, to determine medical necessity and to promote the most efficient use of available health facilities and services.

Findings include:

1. On 5/1/12 at 2:00 PM, Staff #21 was asked to provide for review the report of the professional services reviewed by the UR Committee.

a. On 5/1/12 at 2:45 PM, Staff #21 did not provide for review the report of the professional services reviewed.
Staff #21 stated that the UR committee report was not available since the former Chairman of the UR Committee resigned from the hospital staff during the summer of 2011.

3. All the above was confirmed by Staff #21 on 5/1/12 at 2:45 PM.

Based on observation during tours of patient care areas and staff interview, it was determined that the facility failed to ensure that all equipment was properly maintained.

Findings include:

1. During a tour of the operating rooms (OR) #2 and 4 at the Voorhees Surgical Center, conducted at approximately 10:30 AM on 5/3/12 in the presence of Staff #37, the following was observed:

a. There was a significant amount of rust noted at the base of the OR table in OR #2.

b. There was a significant amount of rust noted at the base of the OR table in OR #4.

c. These findings were confirmed by Staff #37.

2. During a tour of the Pediatric ICU (PICU) conducted at approximately 10:30 AM on 4/30/12 in the presence of Staff #12, the following was observed:

a. There was a significant amount of mineral scale noted on the chutes of the ice maker in the pantry.

b. There was a significant amount of mineral scale noted on the chutes of the ice maker in the second pantry (Room #631.)

c. These findings were confirmed by Staff #12.

3. During a tour of the Radiology Department, conducted at approximately 1:30 PM on 5/1/12 in the presence of Staff #10, the following was observed:

a. There was a coating of dust noted on the monitors and equipment booms over the procedure tables in Interventional Lab #1.

b. There was a coating of dust noted on top of the scanner and equipment booms over the procedure tables in CT Scanner #2.

c. These findings were confirmed by Staff #10.

Based on medical record review, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure that suicidal patients are placed on observation status while in the Emergency Department (ED) in accordance with facility policy.

Findings include:

Reference: The 'Procedure' section of the facility policy titled "ED Patients Requiring Monitoring for Safety" states, "Any suicidal or homicidal patient shall be designated a Triage Level 2 and shall be considered a risk of danger to self or others... The patient shall be placed on an observation status in the ED. The level of the observation status shall be determined by the assessment and subsequent reassessments of the RN/provider and can be changed at anytime during the patient's ED visit...
Types of Observation Status in the Emergency Department
- 1:1...
- Constant Observation...
- Close Observation...
The ED physician shall evaluate the suicidal or homicidal patient and consult psychiatry when deemed necessary. These patients shall be closely observed until they have been discharged, admitted to the psychiatric unit of Cooper Hospital, or transferred to an appropriate psychiatric facility..."

1. Review of Medical Record #30 revealed the following:

a. The patient presented to the ED on 4/14/12 at 2:53 AM with the chief complaint, "Suicidal." Triage Suicidal/Homicidal assessment at 3:00 AM states, "Do you feel like hurting yourself right now?: Yes; Do you feel like harming others right now?: No; Do you have a plan?: Yes (cut self)." Medical Screening Exam completed at 4:28 AM. Evaluated by Psychiatry Resident at 5:32 AM. Plan to discharge home and follow-up with outpatient services. The patient was discharged from the ED at 6:53 AM. There was no evidence that the patient was placed on any type of observation status during his/her stay in the ED for a total of 4 hours.

b. The patient presented to the ED on 4/29/12 at 2:39 AM with the chief complaint, "Suicidal." Triage Suicidal/Homicidal assessment at 3:00 AM states, "Do you feel like hurting yourself right now?: Yes; Do you feel like harming others right now?: No; Do you have a plan?: Yes (pt plans to cut self)." ED notes at 2:50 AM, "... c/o suicidal thoughts, plans to "cut himself", because of increased stress "over life" since this morning, reports being medication compliant and also was hospitalized for 7 days for SI [Suicidal Ideations] approximately a month ago..." Medical Screening Exam completed at 3:46 AM. Note by ED physician states, "Pt seen by psychiatry---cleared for discharge. To f/u as an outpt." The patient was discharged from the ED at 7:00 AM. There was no evidence that the patient was placed on any type of observation status during his/her stay in the ED for a total of 4 hours and 21 minutes.

2. The above findings were confirmed by Staff #1 on 5/2/12 at 2:40 PM.