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Based on observation of the Emergency Department (ED) and Comprehensive Psychiatric Evaluation Program (CPEP) conducted on 5/13/13 with hospital staff, it was determined that signs specifying the rights of individuals and whether the hospital participates in the Medicaid program was not conspicuously posted.
Findings include:
A tour of the ED and CPEP was conducted on 5/13/13 with hospital staff signage specifying the rights of individuals and whether the hospital participates in the Medicaid program was not conspicuously displayed in the ED treatment areas and the CPEP. There was no signage posted in the CPEP, Labor and delivery room, and waiting room.

Based on review of the ED log the facility failed to maintain a comprehensive log that was easily retrievable and included the disposition of all patients in the ED. Specifically, the ED log was incomplete.
Findings include:
The Emergency Department log was requested approximately 10:00am on 5/13/13. The ED log was not presented to surveyors in a timely manner for review. An electronic log was presented approximately 3:30pm which included most of the information requested by the surveyors. The review of the log noted several missing entries in the disposition and time out columns for Labor & Delivery for February, March and April 2013.

Based on record review, review of policy, staff interview and the ED registration log it was determined that the hospital failed ensure that patients who present to the emergency department (ED) receive a timely medical screening assessment.

Findings include:

1. The hospital permitted a deficient practice where patients who arrive for emergency treatment are queried about their reason for seeking emergency care first by a registration clerk prior to triage.

Review of the job description of the ED Registrar on 5/15/13 found that their duties include asking the patient why they are seeking emergency care prior to actual triage by the ED triage nurse. Review of the job description for the Registrars on 5/15/13 found that it included under section (20) " Demonstrates the knowledge and skills necessary to provide care, based on physical, psychosocial, educational, safety and related criteria, appropriate to the age of the patients served in the assigned area.. Under " Age Specific Competencies ( Neonate, Infant, Pediatric, Adolescent, Adult, Geriatric ) it was stated under section (c) provides care for patients based on age-specific needs. Under job hazards/Physical demands, it was stated that the employee must be prepared to lift/move patients, and potential exposure to pathogens and contaminants requiring appropriate understanding and proper use of personal protective equipment and universal precautions.

Interview with the ED registrar on 5/13/13 found that she stated that she always asks the patient for their chief complaint and enters this into the computer under "complaint." If the patient complains of chest pain or asthma, the clerk advises the triage nurse to see the patient immediately and be placed ahead of other patients.

At interview with the ED medical director on 5/13/13 and 5/15/13, it was stated that this practice is not triage and that it was an assessment by a non-professional as to the patients condition and avoids critical patients waiting their turn to be called chronologically.

2. Review of the ED log of patients from 11/1/12 to 4/30/13 (6 months) provided to the surveyors on 5/15/13 who were noted to have walked out prior to triage found the names and chief complaints of approximately 1072 (one thousand and and seventy two) patients who were never triaged but had stated their complaints to the registration clerk. Review of their complaints included chest pain, shortness of breath, asthma and severe headache.


3. Review of 4/4 applicable records on 5/15/13 found a lack of timely medical screening by qualified staff for patients who were seen first by a registrar and who subsequently walked out prior to triage.

Specific reference is made to review of MR #s 4 ,5, 6 ,and #7 on 5/15/13, who were referenced in the ED log for patients who walked out prior to triage and who were interviewed by the registrar with a presenting complaint of chest pain.

Review of MR# 4 found that this 50 year old patient presented to the ED on 11/28/12 at 2332 hours with complaint of chest pain. The patient was " called " for triage at 0028 (12:28 AM ) with a note of "no answer." No EKG was performed .

MR#5 was a 51 year old male with chest pain who presented to the ED on 11/28/12 at 2112 hours (9:12 PM). At 2128 hours (9:28PM) the patient was called for EKG and triage and was noted as "no answer".

MR# 6 presented to the ED on 11/28/12 at 2042 hours (8:42 PM). At 2052 hours (8:52 PM) the patient was called for an EKG and it was completed. There is no record that the EKG was reviewed by emergency department (ED) Medical staff. There is only a review by a cardiologist the next day at 9:16 AM. The patient was never triaged.

MR #7 presented to the ED for chest pain at 1630 hours (4:30 PM). An EKG was completed at 4:34 PM. There was no evidence that any member of the ED medical staff reviewed the EKG. The report was made by cardiology staff the next day at 12:16 am (0016 hours). The patient was never triaged.



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4. Two of nine applicable medical records reviewed on 5/14/13 (MR #s 8, # 9) determined incomplete medical screening examinations, including the lack of prompt assessment of individuals' condition upon arrival to ensure that the individuals were appropriately prioritized based on their presenting signs and symptoms.

a. MR #8: Review of MR # 8 on 5/14/13 at approximately 2:30 PM noted that this 30 year old male brought to the ED by ambulance on 2/13/2013 at 07:40 with chief complaint of "OD." (overdose) The initial triage was dated on 2/13/2013 at 07:46. The initial triage acuity: Level 3 Urgent. VS: BP: 123/62, T: 98, HR: 51, Resp: 12. -The patient was seen by a physician on 2/13/2013 at 08:03. On 2/13/2012 at 08:19, the physician noted "the patient presented with altered mental status after drug ingestion; EMS reports that he took heroin early today; patient is drowsy but arousal to pain. Unable to obtain further history from patient due to altered mental status." The physician noted "unable to obtain further history will observe for sobriety and reassess.". On 2/13/2012 at 12:38, the MD noted "discharge with steady gait." It was noted that the physician discharged the patient without obtaining a complete medical history from the patient. It was noted that the final diagnosis was substance abuse. There was no documentation in the certified medical record reviewed that laboratory work was done to rule out any other medical problems.
It was noted that the last vital signs were taken on 2/13/2013 at 07:59 it was noted that EKG was done on 2/13/2013 at 8:11:13 and the heart rate 47. There was no evidence that vital signs were taken prior to the patient discharged from the hospital on 2/13/2013 at 12:38.

b. MR #9: Review of MR # 9 on 5/14/13 at approximately 3:30 PM noted that this 36 year old male walked into the ED on 11/26/2012 at 14:37 with chief complaint of "chest pain/pericarditis?" It was noted that this patient did not have a full nursing assessment including vital signs until 11/26/2012 at 16:06. VS: T 97.6, BP 124/78, and HR: 72, Resp: 15. The nurse noted past medical history (PMH) of pericarditis; patient stated pain feels the same. It was noted that no tests were done to rule out pericarditis.
It was documented in the record that EKG was completed on 11/26/2012 at 14:39. The result of the EKG interpretation was not documented. There was no notation from the provider who ordered the EKG regarding the result. A copy of the EKG was not located in the certified medical record reviewed.
On 11/26/2012 at 18:42, the nurse noted, "patient not in the Emergency Department, patient walked out." It was noted that this patient who presented in the ED with chest pain waited almost four hours without a complete medical screening.

Based on review of records and procedures, it was determined that patients did not receive sufficient evidence of stabilizing treatment prior to release or departure from the emergency department.
This finding is noted in 2/6 applicable records reviewed.

Findings include:

1. Review of 1/1 applicable records on 5/13/13 determined that a patient did not receive stabilizing treatment prior to being escorted out of the ED by security staff.

Review of certified MR#1 on 5/13/13 for the ED visit of 4/8/13 at 0210 hours found that the patient who presented to the ED by Emergency Medical Service ambulance (EMS) with complaint of shortness of breath and alcohol intoxication. Vital signs taken at 2:11 AM include: 98 Temp temporal, BP= 151/88, HR= 107, and Resp=20. At 2:14 AM, blood glucose =353. At 2:58 AM, nursing noted the patient moved his stretcher and security was called to escort the patient back. At 3:16 AM, the physician noted past medical history of diabetes, hypertension, CHF, COPD, Bipolar disorder, schizophrenia, stroke, past ORIF of left ankle, left knee tendon surgery, and surgery on bilateral hands secondary to stab wounds. Home medications were listed at 3:17 AM. Orders were noted for laboratory work including bnp, metabolic panel, cbc with diff, and troponin at 4:13 AM. VBG was ordered at 4:14 AM along with d-dimer, and cardiac monitor and x-ray for chest pain at 4:15 AM.
There was documentation 4/8/13 at 0411 hours from the ED attending that "psychiatry feels inpatient care needed. Waiting for psychiatric bed this afternoon."
Nursing noted at 0558 the MD was notified about delay in lab work which were still in process. At 6:19 AM the nurse recorded the patient pulled out the heplock; no signs of redness or swelling was noted at the site and a dressing was applied. Patient refused to go to x-ray because he had to go to the bathroom; it was noted the MD was at bedside when the nurse also noted the patient was refusing all further care. The patient used profanity towards staff and was verbally abusive. Security was called.

The patient was escorted by security out of the ED at 0703 hours after he was allegedly using profanity and was verbally abusive to staff at 0619 hours. There is no evidence the patient had any evidence of a psychiatric consultation during this encounter nor any follow up for this evident need.

There was no policy to describe when an officer would be able to remove any patient from the emergency room. Review of Hospital Security Policy and Procedure #223 titled, "Managing Patients Refusing to leave Medical Center Premises," on 5/15/13 found that this policy applied to all parts of the hospital, not only the ED. It stated that "under no circumstances are security staff to physically remove a patient or visitor from the premises." There was no reference in the policy that would require that an assessment of the patient's physical and mental capacity be done by a member of the medical staff and that a such a disposition be entered into the patient's record. Furthermore, there was no direction as to how a patient who still refuses to leave should be managed.

This patient was removed from the ED at 0703 on 4/8/13. There was no record of any admission or consultation with psychiatry. Patient was escorted out of the ED with last vital signs taken at 0420 hours with a sleeping pulse of 106 a respiration rate of 28.

The patient had presented to the Emergency Department (ED) 5 times within the prior 7days, with varied complaints that included " having weird thoughts and hearing voices." These encounter dates include:
--4/2/13 at 1:54 AM : The patient complained of shortness of breath (SOB) and difficulty breathing. The patient was treated with atrovent and albuterol and walked out at 7:06 AM
--4/3/13 at 2139 (9:39PM) : The patient complained of chest pain/SOB. The 4/3/13 ED visit attending note reports: "Patient has been here 23 times in the last 12 months. Keeps requesting narcotic pain medication." The patient was treated and had EKG, chest x-ray where it was noted he had CHF new compared to 12/1/12 and stable cardiomegaly with no pleural effusions.The patient was discharged at 7:37 AM on 4/4/13.
--4/6/13 at 6:13 AM: Patient was brought in by ambulance with intoxication/vodka and beer. Patient was evaluated and discharged at 3:30 PM with security due to agitation. Patient reports hearing voices chronically. Patient refused detoxification admission and shelter referrals, per social work note.
--4/6/13 at 9:15 PM: Patient walked in with complaint of intoxication and reportedly drank 80 oz. of beer and 1/5 of vodka on that date. Altered mental status was noted in the record.The patient was argumentative and threatening in the ED. A complete exam could not be performed. Security officer noted in an incident report that at 2150 hours (9:50PM) that the patient was escorted off the premises with the help of a NY Police Department (NYPD) officer who as transporting a prisoner patient to the emergency room. A nurse noted at 10:22PM (22:22) that the patient was discharged by the MD and security officer .

Follow up documentation was obtained from another acute care facility on 5/24/13. The patient presented to the ED of a second hospital 36 hours later on 4/9/13 with signs of alcohol withdrawal and developed flash pulmonary edema requiring emergent intubation and ventilator assistance. The record also noted that patient also reported command hallucinations to kill persons.


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2. The facility did not consistently take steps to secure written refusal from individuals/ representatives who refuse further medical examination and treatment required for stabilization of identified emergency medical conditions.
This deficiency was noted in one of five appropriate medical records reviewed (MR # 10)
Review of the facility's ED central log for the month of December 2012 on 5/13/13 at approximately 3:30 PM noted that it was documented on the log that the patient in MR # 10 signed out against medical advice (AMA).
Review of MR # 10 on 5/14/13 at approximately 2:00 PM noted that this 54 year old went to the ED on 12/14/2012 with chief complaint of right lower leg swelling. On 12/14/2012 at 13:54, the PA (physician assistant) noted that the diagnosis was cellulitis and the plan was labs, ultrasound (US) and probable admit.
On 12/14/2012 at 16:49, the physician assistant (PA) noted "the patient was not able to be admitted to the hospital as she has commitments at home, she understands the serious nature of the infection and possibility of worsening infection, sepsis and death. She agrees to 1 dose of vanco IV(vancomycin) and she will return immediately if cellulitis progresses."
Review of the, Patients Refusing Treatment or Leaving the Medical Center against Medical Advice form, located in the certified medical record, identified that this form was not completed either by the patient or the provider. There was no documented evidence that this patient signed out against medical advice.

Based on medical record reviews, it was determined that the facility did not ensure that patients with emergency medical condition who require transfer were made aware of the risks associated with the transfer. This finding was noted in 3/ 5 emergency records of patients requiring transfer.
Findings include:
1. Review of MR# 11 on 5/15/13 noted this patient a 47 year old presented to the ED on 3/21/13 at 16:34 with a chief complaint of headache. No significant past medical history, surgical history significant for appendectomy. Labs were drawn and the patient had Head CT scan which revealed a subarachnoid hemorrhage. The patient had a neurosurgery consult.
Nursing documentation on 3/21/13 at 20:13 indicated that the patient was aware of being transferred. However, there was no Patient Transfer Summary and Physician Certification Consent to Transfer forms, located in the MR to indicate that a copy of the ED chart/documents were sent with the patient, that the risks and benefits of the transfer were explained and the patient consented to the transfer.

2. Review of MR# 12 on 5/14/13 noted this patient a 62 year old presented to the Emergency Department on 3/20/13 with right eye injury subsequent to being jumped on by a 50-60 lbs. dog and hit her eye with paw/claw. The patient had CT orbit which revealed a small fracture of the right lateral orbital wall and the posterolateral wall of the maxillary sinuses.
Ophthalmology consult was done on 3/21/13 at 2AM. The decision was made to transfer the patient to another facility for specialty care. The summary noted risks for transfer were listed as motor vehicle accident on the Physician Certification Consent to Transfer Form and not the risks related to the patient's condition/diagnosis.

3. Review of MR# 13 on 5/15/13 noted similar findings regarding lack of risks related to the patient's condition/diagnosis in regards to transfer. The patient presented to the ER overdose of ibuprofen on 11/8/12. The patient was transferred to another area hospital for further care. Review of the Physician Certification Consent to transfer form dated 11/8/12 notes the risks and benefits for "MVA" . This document did not match the patient's issue and did not explain the risks of transfer.