HospitalInspections.org

Based on tours and observation conducted of the emergency department, it was determined the hospital failed to display adequate signs in all required locations of the emergency department which specify the rights of patients to examination and treatment of emergency conditions and including women in labor in accordance with Section 1867.

Findings include:

The hospital did not post signs in all required areas which specify the rights of persons to access care for emergency medical conditions and women in labor.
Tour of the ED pediatric waiting room on 12/9/10 revealed there was no evidence that required signs were displayed in the pediatric waiting room seating area.
Only one sign was posted in close proximity to the entrance in the adult mini- registration pre-triage area. No signs were posted in admitting or treatment areas as required.

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 and accurate ED log as required.

Findings include:

Review of the emergency department (ED) log on 10/5/10 revealed multiple instances (9) of incomplete entries, with respect to missing documentation of vital patient information, such as diagnosis, or patient disposition. In addition, six medical records reviewed revealed discrepancies between the disposition information recorded in the ED register log and data contained in the medical record.

Examples:
Review of the ED log dated 8/30/10 noted this 7 month old child was transferred to another facility ASAP for head injury of left frontal bone when in fact, according to review of medical record #1, he was actually discharged. The medical record noted the child's actual age was ten months, not 7 months, as noted in the ED register log.

Review of the ED log for 1/12/10 determined that a 4 year old male was registered at 11:16 AM and treated and released at 1300 hours. Diagnosis listed was "well check".
Review of the corresponding patient medical record on 12/9/10 determined that this child was seen for diagnosis of alleged sexual molestation. (MR#12) There was no evidence the ED log was corrected for accuracy in this instance.

Review of the ED log dated 10/23/10 noted a 21 year old female unsolicited patient arrived to the ED at 3:50AM. The log was missing documentation of this patient's diagnosis or disposition for this encounter. Review of the medical record corresponding to this patient's encounter (MR #13) noted this patient was brought in to the ED by ambulance for violent behavior and presumptive diagnosis of "EDP" (emotionally disturbed person).The patient was treated in the ED for alcohol intoxication and at 10:56 AM, the staff recorded she was calm and waiting for clothes from "home". The patient left with a boyfriend on 10/23/10 at 12:02 PM. These apparent inconsistencies between the ED log and medical record were not addressed. The log was not corrected to ensure accurate information and disposition for this patient.

Review of the ED log dated 10/31/10 indicated a 30 year old female arrived at 12:46 AM and was treated and released at 0115 AM with a diagnosis listed of "assault by other spec means". Review of the corresponding medical record (MR #14) for this patient indicated that in fact, she had actually walked out. The patient was triaged at 2334 on 10/31/10 following a physical altercation with her father where she was assaulted and punched with a fist . She sustained hematoma to left eye and pain to the right upper arm. The initial MD note at 2335 noted the exam indicated ecchymosis and superficial excoriations to the right neck, hands , and chest. At 0052 (12:52 AM) on 11/1/10 the PA noted the patient walked out prior to registration and completion of the evaluation. No ED procedures were performed.

Review of the ED log dated 5/3/10 noted a 17 year old male (MR #23) arrived to the ED at 1:45 AM and was treated and released at 3:59 AM with documentation written under the transfer column "PEDS 3-5 days". The diagnosis listed in the ED log recorded "induced mood disorder". This was at variance with information recorded in the medical record, which revealed the patient was assessed for complaint of numbness in the right leg and foot. The discharge diagnosis was noted as " pain in limb" and the patient was referred for neurology and pediatric clinic follow up of lumbar radiculopathy type pain.

Review of the ED log dated 5/5/10 noted this 17 month old male was treated and released at 11:39 PM on 5/5/2010 for intracranial injury with a note indicating " PCP 1 day". However, review of the patient's medical record determined this patient, who was assessed after a fall, was not discharged but had actually walked out of the ED before discharge. The record indicated there was an argument between the mother and the significant other and walked out before discharge. The disposition in the MD disposition note in the recorded" walked out before discharge". (MR #24)

The emergency room log patient was missing essential information for the following nine patient encounters as demonstrated by the following examples:
-The ED log for a 33 year old male patient who arrived to the ED at 8:16 AM on 10/23/10 was missing information about this patient's diagnosis and disposition.( MR #15)
-The ED log for a 77 year old female patient who arrived at 7:24 AM on 10/23/10 omitted the diagnosis, disposition, or outcome for this patient. (MR ##16)
- The ED log for a 44 year old female patient who arrived at 9:23 AM on 10/23/10 omitted the diagnosis, disposition, or outcome for this patient. (MR # 17 )
-The ED log for a 36 year old female patient who arrived to the ED at 5:30 AM on 10/23/10 was missing information about this patient's diagnosis and disposition.( MR #18).
-The ED log for a 25 year old female patient who arrived to the ED at 12:05 PM on 10/25/10 was missing information about this patient's diagnosis.( MR#19)
-The ED log for a 64 year old male patient who arrived to the ED at 12:45 PM on 10/25/10 was missing information about this patient's diagnosis and disposition.( MR #20).
-The ED log for a 52 year old female patient who arrived to the ED at 12:47 PM on 10/25/10 was missing information about this patient's diagnosis and disposition.(MR #21).
- The ED log for a 3 year old male patient who arrived to the ED at 7:00 PM on 5/30/2010 was missing information about this patient's diagnosis and disposition.(MR #22).
-The ED log for a 17 year old male patient who arrived to the ED at 4:10 PM on 8/29/10 was missing information about this patient's diagnosis and disposition.(MR #3).

Based upon record review and interview, it was evident that the hospital did not perform a complete medical screening examination on the patient who presented with head trauma.

Findings include:

Review of MR#1 on 12/7/10 found that where the complaint from the parent was that the infant fell from a height of 4 feet to a hardwood floor, a CT was deferred on ED ( Emergency Department ) visit #1. The patient obtained a CT on ED visit #2 when he evidenced vomiting and that CT demonstrated a frontal bone skull fracture.

At interview with the ED Medical Director and the Hospital Medical Director on 12/7/10, it was stated that the infant did not meet the criteria for CT at initial presentation based upon literature that they submitted to the surveyors. Literature cited was " Up to Date entitled Minor Heard trauma in Infants an Children ".

Review of that literature cited, however, injury caused by high risk mechanism injury ( fall more than 3 to 4 feet ) warranted CT imaging in this age group.

Based on record review and interview, it was evident that the corrected report, of an error in reading the CT by another facility, was not received in a timely manner, resulting in a delay in full accurate assessment.

Findings include:

The hospital has a practice where CAT scans performed at the facility at night are read at night at another network facility by a resident and reviewed by an attending. The CT of an infant with head trauma was read as negative and the patient discharged, but approximately 6 hours later the facility that read the CT advised the hospital that a fracture was, in fact, found on the study. This resulted in a recall of the patient.

Review of MR#1 and interview with the ED attending on 12/7/10 found that the CAT scan ( CT ) done at 0230 hours was originally reported as negative by the network facility, this was prior to the infant's discharge at approximately 0430 hours, and was an error as evidenced by a skull fracture. This was communicated to the hospital by phone the following day at 1030 AM to the ED Director , such notice was not given to the appropriate practitioner or the family for at least 3 hours, resulting in a recall to the hospital for neurosurgical assessment and probable transfer to another facility.

This represents an 8 hour delay in accurate assessment secondary to misreading the CT. It is not definitively known at what time the other facility re-reviewed the CT and actually found the fracture. There was, however, no evidence of any intracranial injury on the CT.

This caused a delay in complete neurosurgical assessment. While the original plan was to transfer the patient to another network ( HHC ) facility for neurosurgical management emergently, according to the log, the family requested to be transferred to a non network hospital. The transfer was converted to a discharge by the hospital's medical director when the ambulance that was sent from the non network facility took more than 4 hours to arrive.

The family took the infant to the out of network ( non HHC ) facility by cab at approximately 6:30 PM. The CT was reviewed and the patient examined at that facility The patient was discharged without treatment.



Based on record review and interview, it was evident that the hospital did not ensure the timely transfer of patients for a test that was not available at the facility and was deemed necessary to establish a diagnosis to rule out a surgical condition.

The facility did not formalize a practice where patients are sent to another facility in the HHC network for a test only and where emergency surgery might preclude being returned.

Findings include:

Review of MR2, 3,4,5,6,7,8,9,10, and 11 found that each patient presented to the ED with complaints that the attending felt warranted an ultrasound to, in some cases, rule out testicular torsion, a surgical emergency, or other surgical issues.

Interview with the ED Medical Director 12/8/10 and the Director of Urology 12/9/10 found that the hospital does not have ultrasound services at night and weekends ( coverage ) after a certain hour and relies on transfers to a network hospital for such test and possibly the emergent treatment , if indicated.

Further interview with the Director of Urology on 12/9/10 found that since both facilities involved are in the same network, he knows the staff and communication regarding patient disposition is open even if not formalized.

There was no evidence of a formalized policy that would ensure that the receiving facility perform any emergency interventions deemed necessary as a result of the ultrasound. There was no formal method to ensure continuity of care in that some patients do not return to the ED after the ultrasound and no documentation in the record is made of any results of such test. It is placed in the network facility medical record.

In MR#2, the patient was triaged at 3:52 PM, and at 5:42PM , the transfer form was completed with the diagnosis of possible testicular torsion. The patient was transferred at 8:06 PM, and adding travel time, accounts for a 4 1/2 hour delay.

In MR#3, the patient was triaged at 12:30 AM, the transfer form was completed with the diagnosis of rule out testicular torsion at 1:50 am, but a nursing note states that the patient is still pending transport at 5:37 AM, and the final note is at 8:03 AM.

In MR#4, the patient was triaged at 10:22 PM, the transfer form was completed with the diagnosis of rule out testicular torsion, and the patient transferred at 2:48 AM.

In MR#5, the patient was triaged at 10:30 pm with the physician suspecting possible torsion at 1:48 AM, but the only time in the record that corresponds to a transfer is at 7:35 AM.

In MR#6, the 13 year old patient was triaged at 5:39 PM, the transfer form stated " testicular torsion ", and the ambulance arrived at 8:10 PM. At 7:19 PM, there was an ED MD progress note that describes a request for the network hospital to accept the patient. The ED initial note stated as follows: " The GU resident informed that Pediatric Urology attending does not cover the Metropolitan ER consults during the evening hours and on weekends. The urology attending also informed that he does not cover their ED on those hours. " At some point, ( 7:15 PM ), the patient's father was noted to intend to remove the patient from the ED and take the patient to another out of HHC network hospital by car. The Administrator on Duty is noted as suggesting " to contact that other hospital about accepting that transfer. " There are MD notes at 7:52 PM and 7:55 PM of efforts to get the other out of network facility to accept the patient and take him to the OR emergently if required. This represented a delay in assessment of testicular torsion.

In MR#7, the patient was triaged at 12:03 AM, transfer form indicated " possible testicular torsion " and patient left ED by ambulance at 2:59 AM.

In MR#8, the patient was triaged at 10:08 PM, but the patient's transfer form notes that he was transferred at 1:00 AM with a diagnosis of " rule out testicular torsion. "

In MR#9, the patient was triaged at 11:38 PM, the transfer note that stated ' rule out testicular torsion " was completed and the patient was transferred at 5:40 am. The transfer note notes that the " wrong paper was sent to the receiving facility. "

In MR#10, the patient was triaged at 4:47 PM, the transfer note stated " rule out testicular torsion , needs emergent ultrasound. " There are 2 nursing notes, 1 at 9:03 PM that stated " patient not at the receiving hospital." A 9:04 PM note stated that patient is in MHC-Hallway-stretcher.

In MR#11, the 22 year old patient was triaged at 10:03 PM with specific testicular pain since the morning.. Review of the transfer form found that the indication for transfer was to " rule out testicular torsion ". The transfer form stated that the time of transfer was 4:30 AM the following day. There was an ED MD progress note at 0650 in which the receiving hospital staff stated that they will not send the patient back to the sending facility and that the understanding of the " transfer " was for ultrasound only.