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Based on the review of medical record, it was determined that the governing body did not ensure that the medical staff responsible for the care of the patient in MR #12 document all required information in the patient's medical record.


Findings include:
Review of MR # 12 noted that this 71 year-old male was brought to the Emergency Department from the nursing home by ambulance on 12/5/2010 at 13:27. The presenting problem was hypotension. It was noted that on 12/5/2010 at 15:50 the decision was made to admit the patient. On 12/5/10 at 15:50, the physician noted " MAR was informed of admission, awaiting evaluation " . The admission evaluation and progress notes were not located in the record. On 12/5/2010 at 16:39, the physician noted patient is currently hypotensive. MICU resident notified secondary to hypotension.
It was noted that there was a report of consultation from trauma MICU located in the record. The date and time of the request and the consultation was not documented.
Review of physicians ' orders noted that on 12/5/10 at 19:00 there was an order to admit the patient to MICU. The MICU admission evaluation or the progress notes for the physician responsible for the patient was not located in the record. It was noted that the patient expired on 12/7/2010 at 11:08. This medical record was reviewed on 3/9/2011 during the survey. It was noted that the physician who was responsible for the care of the patient final notes or discharge summary which included the outcome of the hospitalization and disposition was not located in the record. A certified copy of the record was given to this surveyor on 3/11/11 and it was reviewed. It was noted that a discharge summary dated 3/10/11, over the required 30 days, was now in the chart.

Based upon medical record review, review of patients rights information, review of restraint policy, observations and interview, it was determined that the facility failed to meet the Condition of Participation for Patient Rights as evidenced by:

1. The facility failed to provide instructions to non English-speaking patients entering the emergency department and did not effectively inform each patient of his or her rights in advance of furnishing or discontinuing patient care. (See findings at A117)

2. The facility did not consistently provide patients/patients' representatives with prompt resolution of their grievances. (See findings at A118)

3. The hospital's policy indicated that the Governing Body delegates the patients ' grievance to the grievance committee, it was determined that the facility did not effectively have a grievance committee. (See findings at A119)

4. The facility did not consistently assure that patients/patients' representatives the rights to participate in the development and implementation of the patients plan of care. (See findings at A130)

5. The hospital failed to provide care to patients in a clean, safe and secured environment. (See findings at A144)

6. The facility did not ensure patients clinical records were always secured and only viewed by authorized individuals. (See findings at A147)

7. Patients who were restrained using side rails in the up position were not properly monitored (See findings at A159).

8. The facility did not ensure that the patients restrained with chemical and physical restraints that other measures used to protect staff, patients and others from harm were ineffective. (See findings at 164)

Based on observation, it was noted that the hospital failed to provide instructions to non English-speaking patients entering the emergency department.

Findings include:

During tour of the adult Emergency Department (ED) on 3/7/11 at approximately 10: 15 AM, it was observed that the signage on the public entry ED door instruct patients to go directly to triage if they are having chest pain, shortness of breath (SOB) was only written in English.



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Based on unit tour, staff and patients interviews, the review of medical records and other documents, it was determined that the facility did not effectively inform each patient of his or her rights in advance of furnishing or discontinuing patient care. This deficiency was noted in three applicable medical records reviewed (MR# 7, # 10 & #12).

Findings incudes:

During the tour of 6 Snapper a step down unit , on 3/10/11 at 12:50 PM, MR #7 was reviewed. It was noted that this was a 65 year old patient. It was noted that a copy of the An Important Message from Medicare About your Rights (IM) form and the Acknowledgement form; a receipt of the patient rights booklet were located but not signed. This patient was admitted to the MICU unit on 3/2/11 due to CVA. It was documented that the patient was confused at times. However, it was noted that the patient had family involvement. It was documented that the patient's brother visited him on 3/3/11. There was no documentation that this patient rights documents were given or discussed with the patient's family member or the reason why this was not necessary.

On 3/10/11 approximately 1:00pm the nurse assigned to the patient was interviewed. This staff reported that the Patient Rights package is given in the ED but the information is reinforced on the units. This nurse stated that the patient was not given this information because he just arrived to the unit on 3/9/11.

The patient's brother was interviewed on 3/10/11 at approximately 1:15pm. This family member reported that he visited every day. He also stated that the Patient Rights information including IM was never discussed or given to him. The patient also stated that this information was not given to him.

Similar patient findings on IM form not signed by patient in MR # 10;

In MR # 12, this patient was unresponsive in the nursing home and he was brought to the Emergency Department on 12/5/10. It was noted that the patient's wife signed consent for medical procedure. However, there was no documentation why the acknowledgement form was not given to the patient's wife.

Based on review of Patients Complaints/Grievances files and facility's policy, it was determined that the facility did not consistently provide patients/patients' representatives with prompt resolution of their grievances. This deficiency was noted in 3 of 14 files reviewed.

Findings include:
Review of patient grievance file on 3/9/11 at approximately 10:00am for the patient in MR # 22 noted that a written complaint was addressed to the Chairman of E. D. dated 8/30/2010 was located in the file. It was noted that a memorandum was sent on 9/20/2010 at 11:52 AM to the Director of Patient Relations. There was no documentation when the facility actually received this patient grievance. It was noted that a copy of a written response dated 9/22/2010 was located in the file over 21 days after the date of the grievance.

Compliant file # 10-08-012-3 was reviewed. It was noted that the patient's family member filed grievance with the facility's Patient Relation Department on 8/17/2010. It was noted that the outcome of the investigation was completed on 9/16/2010. However, the written response to the complaint was dated 10/5/2010.
-It was noted that the hospital did not inform the complainant that she may file a grievance with the State agency if she was not satisfied with the outcome of the hospital investigation.

The family member for the patient MR # 21 filed a complaint with the facility on 12/8/10 regarding care rendered to his brother in the facility ' s Emergency Department. It was noted that this grievance was received in the Patient Relations Department on 12/13/10, five days after the grievance was filed. It was noted that it took over five days for the Patient Relations Department to receive this grievance hence a delay in written respond dated 12/17/2010 to the complainant.

Based on staff interview, the review of facility ' s Patient/Family/Significant Other Complaints/Grievances policy and Hospital Quality Assurance Minutes, it was noted that although the hospital's policy indicated that the Governing Body delegates the patients grievance to grievance committee, it was determined that the facility did not effectively have a grievance committee.

Findings include:
During the survey at this facility on 3/9/ -3/11/10, copies from the grievance committee for the past 12 months were requested. The facility was unable to provide such documents.

The Director of Patient Relations was interviewed on 3/10/11 at 10:00am. This staff reported that the governing body is aware of patients grievances.
- A copy of Patient Grievance report to the Governing Body 2/1/10 to 2/1/11 was reviewed. It was noted that this documents lists patient ' s complaints/ grievances and the outcome. However, there was no documentation of responses or acknowledgment from the governing body.

The Director of Patient Relations reported that she reports to Hospital Organization Performance Committee (OPIC) four times annually. The OPIC minutes for the year 2010 was reviewed. It was noted that the minutes included patients satisfaction but patients/ patients' representatives grievances were not included; there was no evidence of analysis of trends and implementation of actions necessary to correct identified patient grievances.

Based on medical record review and staff interview, it was determined that the facility did not consistently assure that patients/patients' representatives the rights to participate in the development and implementation of the patients plan of care.

Findings include:
During the unit tour, on 3/10/11 at 11:35 AM, MR # 9 was reviewed. It was noted that this 31 year male was brought to the Emergency Department (ED) by EMS on 12/10/10 due to disorganized behavior. Past history included schizophrenia. It was documented that the patient had supportive caring family. The patient's comprehensive treatment plan was reviewed. It was noted that the treatment plan involved individual, group & family therapy, pharmaco/therapy, advocacy, activity and nursing. It was noted that the comprehensive treatment plan dated 12/14/10 was only signed by the primary therapist and the primary care nurse. It was noted that the form indicated that the patient was in agreement with the plan. It was noted that the patient refused to sign the form. The reason why the patient refused to sign was not documented.

-Treatment plan review forms dated 12/23/10, 12/30/10, 01/5/11, 1/17/11, 1/25/11, 2/2/11, 2/8/11 , 2/16/11, 2/23/11, & 3/2/11 was only signed by the physician.

- The staff interviewed on 3/10/11 at approximately 11:00am reported that the patient had family involvement but there was no documentation that they were involved in the patient's treatment plan.

- The physician and nursing staff interviewed on 3/10/11 at approximately 11:15am reported that the patient was stable and he remained in the hospital due to placement issues. However, there was no documentation that the patient was involved with his treatment plan and discharge plan decisions.


Review of MR # 11 noted that this 31 year old female was bought to the the ED by EMS on 3/3/2011 after an altercation with a male. Past medical history included bipolar disorder. The patient was admitted due to irritable mood, rapid speech and grandiose delusions. Review of the Comprehensive treatment plan noted that the form was not completed as the patient's name, admission date, primary therapist, physician in charge & primary care nurse section of the form was not completed. It was noted that only the primary therapist signed the comprehensive treatment plan. It was noted that there was a section on the form for the patient to agree with the plan and if there was any family involvement. This section of this form was not completed. It was documented that all risks and benefits of psychotropic medications were explained and the patient agreed. Therefore, there was no documentation why the patient did not sign the comprehensive treatment plan or the reason why this was not done.

The staff interviewed on 3/10/11 reported that the patient was stable and the plan was to discharge her in a few days. There was no documentation that the patient was in agreement with this plan.


Review of MR #2 noted that this 41 year old patient arrived to the Emergency Department on 10/14/10 with chief complaint of MVA, pain to left knee and lower back. The patient was triage at 7:31pm at ESI 4- less urgent, vital signs were noted to be T: 97, B/P: 115/78, P: 96, R: 20, pain scale: 3-4. The patient was seen and examined at 22:40 (10:40pm) pain medication was ordered at 10:55pm but not administered until 2:03am, more than three (3) hours later.

Based on observation and staff interview, it was determined that the hospital failed to provide care to patients in a clean and safe environment.

Findings include:
On tour of the 5 Snapper psychiatry unit on 3/10/11, the seclusion room was observed to be in unsanitary conditions. The stench of stale urine filled the air of the seclusion room and the floor of the room was observed to be dirty with urine stain, small debris and paper plate.


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Based on tour, staff interview and other documents, it was determined that the facility failed to provide a secure and safe environment to infants and children at the hospital.

Findings include:
A tour was conducted on the Pediatric (8CHC) unit on 3/10/11 at 11:00AM.
The surveyor was able to open two doors from inside of the pediatric unit leading to the elevator. The door leading to the stairway was locked but all other doors were open. Hospital police were not assigned to the Pediatric unit. Two infants were located in the Isolation Area of the pediatric unit however there was no staff supervising these patients on a consistent basis. There are no surveillance monitors, alarms or wrist band alarm to prevent an abduction of an infant or child.
On 3/10/11 at 11:45 AM the Director of Security was interviewed. He informed the surveyor that there was no security mechanism in place other than staff rounds. He stated that they had a security system in place in the past but the security lock kept breaking therefore they felt this was not a secure system. Surveyor inquired about a wrist band alarm that is currently available at the nursery. Surveyor was informed that it would be too costly to place the band alarm system in the pediatric unit. They would have to break walls and wire the walls which is very costly.
It was determined that there is no mechanical security to protect this vulnerable population. Children are not in a safe environment.

During the tour of the pediatric unit it was noted that the children's nourishment refrigerator was found to be cleaned but had food in 2 brown paper bags that were not label to identify the owner or dated to assess when the food needed to be discarded. A container of soy milk and a can of Pediasure supplement had no label identifying the date or owner. Standard of practice for food safety for foods not located on a meal tray requires that food be labeled identifying the food item, owner and a complete date for infection control .


The medical/surgical unit (5 CHC) was toured on 3/10/11 at 1:00PM with the VP Patient Care Services and the Nurse Manager. It was found that the patient's nourishment refrigerator did not have a temperature log. Therefore, patient's nourishment refrigerator temperatures were not being taken. The patient nourishment refrigerator was dirty with a dry purple food stain at the bottom of the refrigerator, an Accuterm-Hot and Cold Pack located in the refrigerator, a bottle of Arizona Cranberry Cocktail, a dessert that appeared to be rice pudding had no label identifying the food item , no complete date (the dessert had a round yellow sticker with the number 18 on the cover). The number did not identify the month only the day. There was also a brown bag with food that had no patient identification, date or identification of food items. In addition, the nourishment refrigerator contained a salad that was dry, discolored and shriveled. The cover was off the item but the cover was found in the refrigerator with the round dot noting a date 31. Dating a food product with only a date of expiration such as "31" is confusing for the staff that would be providing this food item to the patient.
Staff nurse was asked by the surveyor what the round dot meant and she answered she did not know. The type of salad could not be identified. There was no label identifying the name of this food item or any other item in the refrigerator provided by the Food Service Department. The facility did not follow national standard of practice in labeling and storing patient food in a safe environment.

The surveyor returned to the Pediatric unit (8 CHC) on 3/10/11 at 2:30PM and the children's playroom was toured. It was observed that many toys of all sizes were available for children to play. Surveyor interviewed the Child Life Specialist and a student Intern present in the playroom. Due to the volume, variety of sizes and texture of the toys; staff members were asked about the cleaning and sanitation of the toys. They were also asked if the toys were cleaned off site and if there was a cleaning schedule for the toys. The surveyor was informed they do not have a specific cleaning schedule. They clean the toys at the end of the day on site. No one is specifically assigned to clean the toys. If they can not clean the toys at the end of the day they would place the used toys in a bin to be cleaned the next day. Cleaning agent used to clean and sanitize the toys is Clorox wipes. When asked how they clean very small toys that have ridges, small parts and indentations. They inform the surveyor they just clean the toy with the wipes. No specific procedure they just wipe the toys. Sanitation schedule, process and approved cleaning agents for cleaning toys were not available to secure a safe patient environment.

Based on observation and staff interview, it was determined that the facility did not ensure patients clinical records were always secured and only viewed by authorized individuals.

Findings include:
The Adult Emergency Room was toured on 3/7/11 at approximately 10:15 AM. During this tour, it was observed that several patients medical records containing confidential information were laying around in the fast track area for unauthorized persons to gain access to. It was noted that the medical records for patients ( MR #3, MR # 4 & MR # 5 ) were laying on the top of cabinet outside the treatment area. The medical record for the patient in MR #6 was laying on the counter across directly from the patients waiting area. It was noted that several patients and staff ( who were not providing treatments to these patients) were going to and from the waiting area to the treatment area.

On reviewing MR # 3, #4 & #5 it was noted that these patients were seen in the ED on 3/6/2011.

The Director of ED, Nursing who accompanied the surveyors on the tour replied " these were not supposed to be there " .

Based on medical record, facility's policy and other documents review and staff interview, it was determined that the patient in MR # who was restrained using side rails up was not properly monitored ( # 7).

Findings include:

During the tour of 6 Snapper a step down unit on 3/10/11 at 12:50 PM, MR # 7 was reviewed. It was noted that this 65 year-old-male was admitted to the MICU unit on 3/1/11 with diagnosis of CVA and left side weakness. Past medical history HTN, CHF, CAD. The patient was transferred to this unit on 3/9/11. It was noted that while the patient was in MICU he was found on the floor.
Review of the Patient Admission Database form noted that the patient had a fall risks assessment and the patient was identified at a moderate risk for fall. It was noted that on 3/2/11 at 0300 the nurse noted that safety precaution was maintained. The precaution measures implemented were not documented.
It was noted that on 3/3/11 at 03:20 the nurse noted that the patient tried to climb out of bed and vest restraint was applied. It was noted that on 3/3/11 at 0800 the vest restraint was released. The assessment did not include if the patient no longer required restraints. In addition, the assessment did not include the preventive measures in place and the other means of monitoring in place to prevent the patient from falling.
On 3/4/11 at 15:15, the nurse noted that patient was seen climbing out of bed and he fell before staff could reach the patient ; patient stated that he wanted to go to the bathroom.

-The Department of Nursing Performance Improvement & Patient Safety Program form initiated after the fall was reviewed. It was noted that the recommendation was vest restraint was applied and the patient was reminded not to get out of bed. The improvement measures were unacceptable as it did not address the fact that at the time of the fall the side rails were up and this may have been a contributory factor to the fall. It was documented that the patient had bouts of confusion reminding the patient not to get out of bed was not appropriate for this patient.

The registered nurse assigned to the patient on the day of the fall was interview on 3/11/11. Regarding monitoring , the staff reported that they were two patients in the ICU and she sat between the two patients. However, she did not witness the fall because at the time of the fall she was on her break.
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It was determined that this patient had history of trying to get out of bed was restrained with side rails up. The staff was not close enough to deter him from climbing over the side rails as a result he was able to climb over the rails and fell.

Based on patient's complaint and medical record review, it was determined that the facility did not ensure that the patient in MR #1 was restrained with chemical and physical restraints because other measures used to protect staff, patients and others from harm were ineffective.

Findings include:
Patient in MR # 1 filed a complained with New York State Department of Health stating that she was brought to the Emergency Department (ED) by NYC police. The patient reported that she was under the influence of cocaine and alcohol and she was brutally restrained.

Review of MR 1 # noted that this 43 year-old- female was brought to the ED by ambulance accompanied by NYPD on 9/24/2010. The chief complaint was intoxication. The triage nurse noted that the patient was cursing at police officers, disruptive and aggressive. The arrival time and triage time: 6:41; physical exam :7:34. The nursing assessment dated 9/24/2010 at 7:28 indicated that the patient was combative and hostile. The Medical orders were reviewed. It was noted that on 9/24/2010 at 7:57 Ativan 4 mg IM was ordered and given at 8:07; Benadryl 50 Mg IM was ordered at 7:57 and given at 8:07 and Haldol 5 mg IM was ordered at 7:57 and given at 8:07. It was also noted that on 9/24/2010 at 9:04, 1:1 observation was ordered and was in progress. Bilateral wrist and angle restraints were ordered on 9/24/2010 and the restraints were applied on 9/24/2010 at 9:06.
On 9/24/2010 at 17:40, the nurse noted that the patient appeared quiet. It was also noted that on 9/24/2010 at 18:07, the physician noted " psych came to see the patient but the patient was still under the effects of chemical restraint. They will return once the patient is awake " . It was noted that although the patient was under chemical restraint and 1:1 observation, the physical restraints were not released or the reason why this was not done.

On 9/24/2010 at 19:15, the nurse noted that the patient was resting comfortable. It was noted that the patient had a psychiatric follow-up on 9/24/2010 at 19:15. The psychiatrist noted that the patient ' s insight and judgment were impaired due to substance intoxication but the patient had no suicidal or homicidal thoughts elicited and no perceptual disturbance noted. On 9/24/2010 at 19:30, the nurse noted that the patient was on 1:1 observation. However, a physician ' s order dated 9/24/10 at 19:30 for bilateral ankle and wrist restraint was noted. The reason for the restraint was not documented. It was noted that the re-assessment documenting the reason for the continued physical restraint was not located in the record. It was also noted that there was no documentation that the patient was educated on the reason for the restraint.

On 9/24/2010 at 20:30, the nurse noted that the bilateral ankle restraint was removed. The nurse noted that the patient was discharged on 9/24/2010 at 21:51. The date and time that the bilateral wrist restraints were released was not documented.

Based on medical records review, unit tour and Emergency Department Flow Reports to QPIC, hospital policy, it was determined that the facility did not ensure that all emergency services requirements were met.

Finding include:
During the tour of the facility's Emergency Department (ED) on 3/7/11 and 3/11/11, it was noted that patients who walked into the ED for treatment printed their names on the sign-in sheet and waited to be seen by the triage nurse. There was no slot allotted for arrival and waiting time. There was no other mechanism where arrival time was recorded.

Patient in MR # 14 who was interviewed on 3/7/11 at approximately 10:20 AM reported that he arrived in the ED waiting room at around 9:00 AM . This patient stated that when he arrived in the waiting area no staff was in the triage area. This patient's presenting problem was hand injury. The patient reported that he was unable to sign in and so his name was not listed on the sign-in sheet; he stated he was called to triage later than his arrival time.
Review of his medical record noted that the arrival time was on 3/7/11 at 9:57 and triage time was on 3/7/11 at 9:58.

The surveyor arrived in the ED waiting area at approximately 10:15 AM on 3/7/11, the patient in MR # 17 had signed in and she was waiting to be seen. This patient was interviewed on 3/7/11 at 10:25 AM, ten minutes later . This patient had concerns when this surveyor picked up the sign in sheet as she was next on the list. The patient reported that she was already waiting more than five minutes before the surveyor arrived in the waiting area. Her presenting symptom was leg pain. This patient was called by the triage nurse a few minutes later.
The medical record was reviewed on 3/8/11. It was noted that the patient ' s arrival time and triage time were both listed at 10:30 AM..

Review of Emergency Department Flow Report to OPIC for the past 12 months ( 2/10- 3/10) noted that the department was tracking the time to complete triage in minutes. The goal was five minutes. It was noted that this did not capture the patient's arrival and waiting before triage.

Review of MR # 15 noted that this patient , 30 year-old- female veteran, was brought to the ED on 6/9/10 at 20:47 by ambulance. The patient was placed in triage category 3 ESI-3 urgent. The patient ' s history included seizure disorder and hypoglycemia. Chief complaint seizure x 2; the patient had an episode of seizure in the ED. VS: T 97.4, P 80, R 18, BP 124/75. physical exam was 21:44. The patient was medicated with Ativan 2mg IVP at 21:47 & Keppra 1000 mg orally on 6/10/10 at 2:51 AM. On 6/10/2010 at 5:48, the physician noted advised the patient to add another medication Depakote 250mg but the patient refused. The patient was discharged to home on 6/10/10 at 6:28.
- The patient did not have a complete evaluation as the assessment did not include if the patient was in compliance with her current seizure medication. The history did not include prior seizure activities. It was noted that this patient resided in a shelter. It was also noted that the patient was seen in the ED on 6/4/10 due to domestic violence. These issues were not addressed or discussed with the patient prior to discharge home on 6/10/10 at 6:28 AM. This patient returned to the ED on 6/10/10 at 11:12AM by ambulance with presenting symptom seizure and left without medical screening evaluation on 6/10/2010 at 11:50 AM.

Review of MR # 16 noted that this 21 year -old - female was brought to the Emergency Department (ED) by ambulance on 2/12/2011 at 6:28 AM. triage time: 6:28 -triage category 3 ESI-3 Urgent. The chief complaint: seizure and ETOH intoxication. Medical history include DM & Seizures. VS: T 98, R 95, BP 110/55, O2 100%. F/S 370 mg/dl - The patient left without medical screening on 2/12/2011 at 8:34. It was noted this patient waited over two hours without being seen by a provider.
- On 2/12/2011 at 8:00, the nurse noted at 7:30 received patient in corridor c/o seizure, and alcohol noted on breath; blood drawn and sent to lab. On 2/12/2011 at 8:33, patient not seen on stretcher. The nursing assessment did not include last diabetes medication or seizure activity.
Based on the above, it was determined that all patients seen in the Emergency Department did not receive a complete assessment for a proper medical evaluation.


Review of MR # 20 noted that this 63 year- old-male with medical history of anemia, prostate hypertrophy, osteoarthritis & schizophrenia presented in the Emergency Department on 1/3/2011 at 9:01 after a fall. The patient sustained laceration to his right brow. The patient denied loss of consciousness. Head CT scan revealed no acute fracture or intracranial hemorrhage; chest x-ray showed no acute disease. The laceration was sutured and the patient was admitted. The admitting diagnosis was syncope. On 1/4/11 while in the ED waiting for a bed, the patient choked on a sandwich and died. There was no evidence that the case was reported to the State Agency as required.

Based on review of medical record, facility's policy and other documents, it was determined that the facility did not consistently ensure that all patients seen in the Emergency Department were provided with appropriate referrals prior to discharge.
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Findings include:

Review of MR # 8 noted this 13 year-old- female was seen in the ED on 2/11/2010. The triage time was 20:40; placed in Triage category 3 ESI-3 Urgent. The chief complaint: "mother stated that she was raped."
The patient gave a history of sexual abuse for three month. She stated that she was raped at gun point three months ago. It was noted that the patient had a pelvic exam and HIV testing and counseling and sexually transmitted disease tests were performed. However, this patient did not have a complete and comprehensive assessment as the patient ' s psychological and emotional status was not included or the reason why this was not necessary. The trauma of the assault and the impact on the patient was not assessed. It was noted that the patient engaged in risky behavior but education and counseling was not explored with the patient or the reason why this was not necessary.
-The patient was discharged to home with diagnosis of sexual abuse, sexual assaulted suspected and sexual assault.

Review of Referral to Social Worker policy noted that one of the referral criteria was sexual assault victims but this patient was not referred to social work or the reason why this was not necessary.


Patient in MR # 13, this 22 year old patient presented to the Emergency Department on 10/16/10 with complaint of sexual assault and right ankle pain. The patient was triage at 7:47AM and vital signs noted to be T. 97, B/P: 107/60, P: 92, R: 20, Pain scale 3-4. Nursing documentation indicated that social worker will evaluate the patient, HIV testing and cons. The patient was discharged home at 18:20.
It was noted that there was no documentation that the patient had a complete assessment in order to determine if there was any emotional/mental impact of this inappropriate sexual contact. There was no documentation by social services to indicate that the patient received supportive services to meet her needs or any documented referral.

Based on medical record review and facilty's policies and procedure, it was determined that the facility did not insure that its policies were properly implemented.


Findings include:

Review of MR# 8 noted this 13 year old female presented in the Emergency Department (ED)on 2/11/2010. The chief complaint was sexual assault . This patient was placed in triage category 3 ESI- 3 ( urgent)
Review of the facilty's Sexual Assault Victim policy noted that patients present in the ED with sexual assault are to be assigned to ESI triage 2.

- According to the facility's Sexual Assault Victim policy, security is required to maintain the chain of custody of the rape kit for 30 days.
Review of sexual evidence log on 3/11/11 noted that the patient listed in the log under log # 105-10 was collected on 8/21/10 and the evidence was discarded on 10/19/10; log # 106-10 was collected on 10/25/10 and the evidence was discarded on 3/9/11. It was noted that this evidence was discarded during the survey and maintained more than the required 30 days.

Based on personnel credential files reviewed it was determined that their was not adequate personnel with updated training.

Findings include:

Seven of Eight physician's credential files reviewed revealed no updated Advanced Cardiac Life Support(ACLS) training.



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Based on observation, review of medical records and the facility's policy , it was determined that the facility did not ensure that the personnel responsible for assigning triage category place the patients in the appropriate triage category, based on there presenting symptoms. This deficiency was noted in seven of ten applicable records reviwed ( # 8, #13, #15, #16, #18, #19 & # 23)

Findings include:

Review of MR # 15 noted that this patient , 30 year-old- female veteran, was brought to the Emergency Department by ambulance on 6/9/10 at 20:47. The patient ' s history include seizure disorder and hypoglycemia. Chief complaint seizure x 2; the patient had as an episode of seizure in the ED. The patient was placed in triage category 3 ESI-3 urgent.


Patient in MR # 18, this 19 year old patient was seen in the ED on 1/5/2011 at 09:05. The presenting problem was chest pain. This patient was placed in triage category 3 ESI- 3 urgent.

Patient in MR # 19, this 42 year old female with medical history included , CAD and End Stage renal disease presented with chest pain on 2/2/2010 at 10:12 and physical exam at 10:30. This patient was placed in triage category 3 ESI- 3 urgent.

Review of MR # 16 noted that this 21 year -old - female was brought to the Emergency Department (ED) by ambulance on 2/12/2011 at 6:28 AM. triage time: 6:28 -triage category 3 ESI-3 Urgent. The chief complaint: seizure and ETOH intoxication. Medical history include DM & Seizures. VS: T 98, P 95, R 19,BP 110/55, O2 100%. F/S 370 mg/dl. This patient left without a medical screening exam.


Review of MR # 8 noted this 13 year old female presented to the ED on 2/11/2010. The chief complaint was sexual assault . This patient was placed in triage category 3 ESI- 3 ( urgent); based on sexual policy this patient was to be assigned to ESI triage 2.

Patient in MR # 23, this 26 year old female presented in the ED on 1/10/2011 triage 20:09 VS: 98.1, P 84, R:18, BP 139/68; pain scale 7-8. The chief complaint neck and back pain. This patient was placed in triage category 3 ESI- urgent

Patient in MR #13, this 22 year old female presented to the ED on 10/16/10 with chief complaint of sexual assault and right ankle pain. This patient was placed in triage category ESI-3 urgent and not in category ESI- 2 as per the facility's policy for sexual assault.

Based on Triage policy, the above cases did not belong in the same triage category.