HospitalInspections.org

Based on review of four (4) of twenty-three (23) medical records, review of hospital policies and procedures, and review of rules and regulations of the medical staff, it was determined that the hospital failed to provide an appropriate medical screening examination within the hospital's emergency department to determine whether or not an emergency medical condition exists.

Findings include:

Reference #1: The RULES AND REGULATIONS of the MEDICAL STAFF OF CAREPOINT HEALTH - HOBOKEN UNIVERSITY HOSPITAL states: "..... 11. PATIENT DISCHARGE A. Patients shall be discharged only on written or telephone order of the attending practitioner. The attending practitioner shall make every effort to discharge the patient as soon as possible within the dictates of reasonably proper care and treatment of the patient. ..... B. Final diagnosis shall be recorded in full, without use of symbols or abbreviations, and dated and signed by the responsible physician at the time of discharge of all patients. This will be deemed equally as important as the actual discharge order. ....."

Reference #2: Facility policy and procedure titled, "Psychiatric Patient in the ER (Emergency Room), Management" states: "Purpose: To ensure that all Patients [sic] who present to the Emergency Department with a psychiatric complaint will be evaluated by Qualified Medical Personnel and Crisis Worker. Policy: ..... Patient who is identified to be potentially suicidal or homicidal will be classified as urgent and prioritized accordingly. Patients who are potentially suicidal or homicidal must have a Security Check completed and be closely observed. ..... 3. The Crisis Worker will be called to perform an assessment/evaluation of the patient. He/she will perform a more detailed evaluation and initiate the appropriate interventions and disposition planning in cooperation with the ED (Emergency Department) staff and the psychiatrist on call. ....."

Reference #3: Facility policy and procedure titled, "Triage in the ED" (Emergency Department), states:
"Policy: All patients who present to the Emergency Department for care will be triaged by a Registered Nurse (RN) to determine urgency of care needs. ..... Patients who remain in the waiting room will be periodically reassessed for changes in condition and prioritized accordingly.
.....
Procedure:
.....
Triage RN Responsibilities:
.....
9. Reassesses patients if there is an unavoidable delay in treatment and patients must be sent to the waiting room after triage. Patients with triage level of IV or V may be sent back to the waiting room. If there is a change in the patient's condition, reassess, prioritize and document. .....
Medical Screening Examination and Care:
All patients who present to the ED will receive a medical screening examination (MSE). Medical Screening examinations will be performed by the provider assigned to the ED.
....."

Reference #4: Facility policy and procedure titled, "Evaluation and Discharge of ED (Emergency Department) Patients" states: "..... Policy: ..... Patients presenting to the Emergency Department should receive at least initial evaluation by an emergency or attending physician or physician assistant within four (4) hours of arrival. ....."

1. Review of the medical record of Patient #1 revealed:

a. The patient presented to the Emergency Department (ED) on 8/19/19 at 11:25 AM. The "Chief Complaint" section of the triage assessment stated: "Psychiatric Evaluation." The "Triage Comment" section stated: "pt [patient] reports hearing voices. Pt is well known to Emergency room [sic] for same complaint."

b. A history and physical examination was documented as having been performed at 11:48 AM. No orders were given. The Disposition section of the H&P (History & Physical) documented at 11:56 AM stated, "Routine/Home" in "fair" condition.

(i) There was no documentation that the patient was evaluated by a Crisis Worker, or that a Crisis Worker was called to evaluate the patient. Administrator #21 stated during interview on 8/27/19 that a written order that the patient be evaluated by a Crisis Worker should have been written.

(ii) There was no written order that the patient be discharged.

2. Review of the medical record of Patient #22 revealed:

a. The patient presented to the ED on 1/26/19 at 11:20 PM. The "Chief Complaint" section of the triage assessment stated: "Psychiatric Evaluation." The "Triage Comment" section stated: "Patient well known to the ED states (he/she) is 'hearing voices.' Patient recently discharged from the ED for the same complaint."

b. A history and physical was documented as having been performed at 11:37 PM. An order for Tylenol for headache was entered at 11:48 PM and the medication was documented as having been administered at 11:48 PM. The "Patient Discharge Information" section included the entry: "Emergency Discharge Date/Time: 1/26/19 23:55 (11:55 PM)."

(i) There was no documentation that the patient was evaluated by a Crisis Worker, or that a Crisis Worker was called to evaluate the patient. Administrator #21 stated during interview on 8/27/19 that a written order that the patient be evaluated by a Crisis Worker should have been written.

(ii) There was no documentation that the effectiveness of the Tylenol was evaluated.

(iii) There was no written order that the patient be discharged.

3. Review of the medical record of Patient #23 revealed:

a. The patient presented to the ED on 8/1/19 at 2:04 PM. The "Chief Complaint" section of the triage assessment stated: "Psychiatric Evaluation." The "Triage Comment" section stated: "Patient presents for non commanding auditory hallucinations; denies SI/HI [Suicide Ideation/Homicide Ideation]."

b. A history and physical was documented as having been performed at 2:10 PM. The "Additional Complaints" section of the HPI (History of Present Illness) subsection of the H&P stated: 58 year old (male/female) with a history of schizophrenia and bipolar disorder presents to the ED for evaluation of auditory hallucinations. Patient is a frequent visitor to the ED for the same complaint as well as malingering. (He/She) was recently seen by a psychiatrist in this facility and discharged. ....." No orders were given. The "Patient Discharge Information" section included the entry: "Emergency Discharge Date/Time: 8/1/19 15:37 (3:37 PM)."

(i) There was no documentation that the patient was evaluated by a Crisis Worker, or that a Crisis Worker was called to evaluate the patient. Administrator #21 stated during interview on 8/27/19 that a written order that the patient be evaluated by a Crisis Worker should have been written.

(ii) There was no written order that the patient be discharged.

4. Review of the medical record of Patient #18 revealed:

a. The patient presented to the ED on 3/29/2019 at 19:21 (7:21 PM) via ambulance with a complaint of weakness and fatigue.

b. The patient was triaged at 19:35 (7:35 PM), classified as ESI (Emergency Severity Index) 4, and moved to the ED lobby.

c. The patient left the ED on 3/30/2019 at 01:30 (1:30 AM), six hours and 9 minutes after arrival

(i) There was no documentation of a MSE being completed for this patient.

(ii) There was no evidence of documentation of a reassessment performed by the triage nurse, in accordance with facility policy (Reference #3).

(iii) The above was confirmed by Staff #22 during an interview.