HospitalInspections.org

Based on review of the Emergency Department Central log (ED log) it was determined that the facility did not ensure that it had a complete ED log as required.

Findings include:
Review of the facility's ED log for the month of August 2010 noted that 20 patients had no dispositions noted . Similar findings for missing dispositions were identified for the months of July, September & October 2010.

Based on record review, review of policies, job description, observation, and interviews , it was determined that the ED Registration clerk was performing duties consistent with triage.

Findings include:

The ED ( emergency department ) maintains a system in triage that includes a " mini-registration " process prior to seeing a nurse and that process includes the ED Registrar inquiring into the patient's complaint and making certain observations that determine the time of access to actual triage. There is a security guard posted in the waiting room who provides direction to the patient.

Review of all ED medical records on 11/5 /10 and 11/8/10 found that the ED registration clerk enters data defined as a mini-registration process into the computer and enters that time into the ED record . This information includes the patient's chief complaint which is then medically coded.

Based on interview with the ED Nurse Manager, the registration clerk on duty 11/5/10 and her supervisor 11/8/10, it was stated that the ED registrar copies from a piece of paper provided to the patient or directly from the patient information that includes the patient's complaint. At interview with the security guard on duty 11/5/10, it was stated that when a patient arrives in the ED , the patient is directed to the ED registrar first, not the triage nurse and that a slip of paper is provided to the patient to complete while standing at a podium in front of the waiting room chairs. The patient is directed to submit that paper to the registrar, not the nurse and to communicate to the registrar, not the nurse.

The registrar then refers to a list on the wall titled " Priority Triage " ( Red Box ) and drops the paper into a red box in the adjoining triage nurse's window and notifies the nurse of the patient's presence if the patient meets any of those criteria or " looks sick. " . If the patient presents with a complaint that the registrar deems is not as urgent or appears " well ", then the slip of paper is placed into a " white box " in the triage nurse's office to be called in time order. At interview with the ED Registrar on 11/5/10, she stated that she received no training in the assessment of patients.

Review of the job description of the ED registrar provided by the Admitting Office supervisor on 11/8/10 found no reference to the taking of patient's complaints or the process described above or any training relevant to it. The ED registrar is not supervised by the ED manager but rather the Admitting Office Supervisor for accountability, supervision, and evaluation.

Review of ED triage policy and procedure did not describe this role. Observation on both 11/5/10 and 11/8/10 found that the ED clerk did place small white paper slips with the patient's complaint and other information into red or white boxes. The content of these paper slips included the chief complaint and is written in English and Russian.

Review of medical records found medical records whose disposition was " LBT "defined as " left before triage. " and that complaints were noted on these records with diagnostic codes assigned.

Review of medical records # 2, 5, 7, 8, 9, on 11/5/10 found that some of the patients left prior to triage after waiting for protracted periods to been seen by the triage nurse. The average wait in these patients were 45 minutes prior to the patient leaving the ED. There was no indication in the record whether these patients were placed in the Red or white box.

Based on record review, it was determined that the patient who arrived by ambulance following a motor vehicle accident ( passenger rear-ended ) failed to receive any medical screening examination. The patient was kept out of the treatment area for 5 hours. The intent was to utilize a fast track bed for the patient.

Based on review of triage policy , there is no evidence of the formulation of a policy as to the types of patients that may be placed in the waiting room even though they present via EMS.

Findings include:

Review of MR#1 on 11/5/10 found that the patient who arrived at the ED at 2118 ( 9:18 PM ) by EMS was not triaged until 2142 ( 9:42 PM ). Patient had not been immobilized by EMS and no such immobilization was implemented in the ED. There is an entry at 2149 (9:49 PM ) " triage interventions not applicable ." There is evidence that while the patient was triaged as a patient brought in by EMS, she was placed in the waiting room and remained there for the entire hospital stay.

At 0247 ( 2:47 AM on 9/6/10 ) there is a note that states " patient called to treatment area - no response ." This was repeated at 3:35 and 3:56 AM with no response. The disposition is noted as LWBS ( left without being seen ).

There is evidence that the patient was in the waiting room as indicated by the sections labeled "bed assignments" and "status activity" in the medical record, which revealed the following timeline:
-Status/Activity: Patient was awaiting triage in INU on 9/5/10 at 21:34 (9:34 PM)
-Bed Assignments: The patient was assigned to WR-INU on 9/5/10 at 21:35 (9:35 PM);
-Status/Activity: The patient was awaiting a fast-track bed , C10H on 9/5/10 at 21:50 (9:50 PM);
-Status/Activity: Patient to be seen , C10H on 9/5/10 at 21:51 (9:51PM);
-Bed Assignments: The patient was assigned to FT-2 C10H on 9/5/10 at 21:52 (9:52PM);
-Status/Activity: Patient awaiting fast track bed, GTA on 9/5/10 at 22:01 (10:01 PM)
-Bed Assignments: The patient was assigned to WR GTA on 9/5/10 at 22:01 (10:01 PM)
-Status/Activity: The patient was released GTA on 9/6/10 at 03:56 (3:56 AM)

Interview with the ED Nursing Director on 11/10/10 by phone defined the abbreviations referenced above. The employee stated that "WR" is the waiting room, "FT " is fast-track, and all remaining entries refer to employee electronic identification codes. Consequently, the employee confirmed via interview that the patient remained in the waiting room for the entire emergency department stay.

Based on record review and staff interview, it was evident that there were inconsistencies in the medical record regarding the circumstances under which the patient was found in cardiac arrest in the waiting room could not be established. The patient expired in the ED. As a result of these inconsistencies, the validity and accuracy of the presentation, assessments and interventions as well as their timeliness cannot be established.

Findings include:
During the tour of the ED on 11/5/10 it was observed that a security officer is posted in the waiting room and a registration clerk is adjacent to the security officer.

The facility staff who was interviewed on 11/5/10 reported that security and the registration clerk are at their assigned area 24/7 and the registration clerk is able to observe the patients in the waiting area.

Review of MR#3 on 11/8/10 noted that the patient was seen in the ED on 9/1/10.
Specific reference is made to an entry under chief complaint timed at 0554 hrs " while walking into ED patient collapsed. ". There is no reference to indicate whether the patient was observed to have collapsed by the staff or whether this was information provided by the person accompanying the patient. There is a note that " as per wife, patient was complaining of chest pain since yesterday." It did not state that the wife reported the " collapse " of the patient to a staff member. The record did not note any involvement by the registration clerk or security staff even though there is a security guard permanently posted at the triage booth location 24 hours a day.

Under the entry titled " objective nursing note:" it is stated : " patient found pale, diaphoretic face down on floor in waiting room. Patient agonally breathing, foaming from the mouth , placed on stretcher and brought to room 4. ( 0555 hours.).

Under vital signs timed at 0559 hours, the pulse is noted at 46 and respirations at 8.

Review of the Adult Code flow sheet. however, finds that at 0559 hours, the rhythm is V-fib, which never has a pulse palpable, pulse is " absent ", the patient was being defibrillated with 300 joules, and CPR has been in progress from 0548.

Review of the " Status Activity " portion of the ED record stated that the patient is " awaiting triage " at 0545. Under " Bed Assignments " is entered WR ( waiting room ) 0546 hours. A rhythm strip timed 0545 hours with the word " paddles " was found on the record as the initial rhythm strip.

There is a Quick ED Registration form found that is timed 0552 AM.


Based on record review it was evident that the ED did not ensure the safety of a patient who arrived in triage by ambulance whose chief complaint was severe abdominal pain and who was noted as extremely agitated and restless on arrival to the triage area of the ED.

Findings include:

Review of MR# 4 on 11/8/10 found that the patient who had been shouting, moaning and screaming en route tipped the EMS stretcher in an attempt to get off it in the triage area of the ED . The patient had abdominal pain rated by her as 10 out of 10. . There is no evidence that the ED staff assessed that the patient's agitation, severe pain, and restlessness required a supervised EMS stretcher to ED stretcher transfer involving hospital staff assisting the patient.. Instead, the record indicated that the patient was " able to transfer by herself to the stretcher. "


16790


Based on record review, the facility did not ensure that each patient who comes to the emergency department (ED) has an appropriate medical screening examination in order to determine whether or not an emergency medical condition exists.

Finding include:
Review of MR # 14 noted that this 5-year old patient was seen in the ED on 10/4/2010 at 19:53 with presenting problem of neck pain. The triage nurse noted that the patient had bilateral neck swelling. The nurse noted that the mother requested a "CT of the neck" It was also noted that the patient left without being seen by a medical provider on 10/05/10 at 00:02. It was noted that this patient was placed in Level 5- non-urgent triage category. This child waited over four hours for a medical evaluation but was not seen. It was noted that the patient did not have a complete nursing assessment as the history did not include how the patient obtain the swelling or why this was not necessary. There was no evidence that the patient was interviewed in order to make a complete assessment for an appropriate medical evaluation.

Review of MR #16 noted this 51 year old patient was seen in the ED on 10/2/10 at 20:15 with presenting problem of 1 cm laceration to the right forearm. The patient was placed in triage category Level 4; the patient left without being seen by a medical provider on 10/3/10 at 01:12. It was noted that the patient's blood pressure was recorded at 184/100. It was noted that the triage nurse noted that the patient reported having "white coat syndrome"; the patient's normal blood pressure was not documented. The nurse noted that the patient did not know the name of his blood pressure medication. The last time that this medication was taken was not documented. These responses were required for an accurate medical screening.

Based on record review it was determined that the facility did not effectively ensure that all individuals with an emergency medical condition were effectively made aware of the need for further medical examination and treatment as required to stabilize the medical condition.

Findings include:
Review of MR # 15 noted that this patient was brought to the Emergency Department (ED) by ambulance on 10/4/2010 at 05:41 with chief complaint of seizures. It was noted that the patient had a medical evaluation on 10/4/10 at 08:20. It was noted that the diagnosis was listed as " AMA". It was noted that, on 10/4/10 at 12:16, the nurse assigned to the patient documented that the "dispositions is eloped". This staff noted that the patient/family announced that they were leaving even thought they were advised to stay. The nurse noted that the patient refused to wait for the MD & signed AMA. A copy of the leave against medical advice form (AMA) was not located in a certified copy of the medical record reviewed. The staff documentation of the dangers of leaving against medical advice was not located in the chart.

Based on medical record review, it was determined that the facility sought payment before appropriate medical screening evaluation was performed.

Findings include:

Patient in MR # 10 came to the ED on 9/1/10 for swelling of her legs and difficulty urinating. The medical record face sheet indicated that the patient was registered at 21:40, triage at 22:08 subsequent to which insurance information for the source of payment was collected and not examined by the physician until 23:43.

Patient in MR #6 came to the ED on 10/6/10, the medical record face sheet indicated that the patient was registered at 10:04 p prior to being called to triage at 1:39 a. Nursing notes documented that "he did not want to be triaged because he did not want to be billed he was told to come back after 3 days for check up in ED for his cellulitis on left foot."

Based on medical record review, it was determined that the facility was not consistently ensure that all patients with emergency medical condition who required transfer were made aware of the risks and benefits of the transfer.

Findings include:

Review of MR #11 noted that this patient came to the Emergency Department (ED) on 10/1/2010 for an overdose of Hydrochlorothiazide (HCTZ) and suicidal ideation. The Physician's Certification Consent to Transfer form was reviewed. It was noted that the physician did not fully explain the risk and benefits to the patient based on the patient's condition/diagnosis.

Review of MR # 12 noted that the patient is a 3 year old who was seen in the ED on 9/4/2010 due to a fever/dehydration. It was noted that the patient was transferred to another facility as this facility does not provided Pediatric services. It was noted that the risk & benefit was listed as car accident.

Review of MR # 13 noted that this 71 year old patient was brought to the ED by ambulance on 9/5/2010 after he was found unresponsive at home. The patient was transferred to NY Weill Cornell Medical Center for speciality care. It was noted that the consent to transfer form signed by the patient's family listed the risks as "MVA en route".