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Based on findings from observation and interview, the emergency department (ED) did not ensure that medication, needles and syringes were securely stored. Specifically a syringe with a 22 gauge needle, a saline flush syringe, and multiple syringes and needles were left unattended and unsecured in the ED.

Findings include:

-- Per observation in the ED on 11/2/15 at 11:15 am, in an unattended area in the hallway between rooms 2 & 3, a syringe with a 22 gauge 1½ inch needle attached and a 10 cc saline flush syringe were on the desk and accessible to the public.

Also during observation of the ED on 11/3/15 at 9:30 am with Staff #1, the medication area contained unlocked drawers filled with syringes and needles that were accessible to the public.

-- Per interview of Staff #1 on 11/3/15 at 11:15 am, the above findings were acknowledged.

Based on findings from observation and interview, emergency services department (ED) staff did not ensure that infection control practices were consistent with generally accepted standards. The following was observed in the ED: two ripped seat covers in a patient care area, patient supplies stored on the floor, a staff member did not wash her hands or patient care equipment between patients, and the ED medication area contained dirty and clean equipment / supplies together (e.g., contaminated patient care items were stored with intravenous medication). These lapses in infection control practice may have placed patients at an increased risk for infections.

Findings include:

Observation of the ED on 11/2/15 identified the following:

-- At 10:34 am, in Room 1 A-1 B, two rolling stool's vinyl seat covers were cracked in multiple areas allowing visualization of the under pads. The exposed under pads were not washable.

-- At 11:00 am, in "stretcher storage" room, 3 packages of unused culture swabs, multiple patient hygiene basins, a box of splint kits were all stored directly on the floor.

-- At 11:30 am and again on 11/3/15 at 10:45 am Staff #2 did not clean patient care equipment or perform hand hygiene between patients. Upon interview Staff #2 indicated she was nervous while being observed and that was why she did not perform hand hygiene or clean patient care equipment between uses.

Observation of the medication area in the ED on 11/3/15 identified the following:

-- At 9:30 am, clean and dirty items were stored together. An open rack of medication cups and 10 cc vials of sodium chloride were stored next to a hemacue machine (contaminated). A sharps container labeled "Hazardous compatible waste" was stored next to a pill crusher and two 1000 ml bags of normal saline. A stack of clean patient hygiene basins was stored on top of several books. Inside the patient basins was a pneumonic cylindrical container used to transport blood and urine specimens to the laboratory (via a pneumonic tube transport system).

-- The above findings were acknowledged by Staff #1 at the time of the observations.

Based on findings from observation, document review and interview, care in the ED did not meet minimum standards. Specifically, 1) in 5 of 16 medical records (MRs) reviewed patients were not triaged upon arrival to the ED (Patients A, B, C, D and E). 2) In 3 of 16 MRs reviewed the assigned triage level was inaccurate (Patients C, E, and F). Additionally, 3) the ED did not comply with Federal regulations regarding posted notices. A notice outlining the rights of all patients in compliance with the Emergency Medical Treatment and Labor Act was not posted.

Findings pertaining to (1) above include:

-- During a tour of the ED waiting room on 11/2/15 at 10:30 am, Patient A was observed sitting in a chair. At 11:35 am he was observed going into the triage room. Review of Patient A's MR described a 9 year old male who presented to the ED with his father on 11/2/15 at 10:10 am with a rash on his face. He was triaged at 11:36 am, one hour and 26 minutes after presentation.

Patient B's MR described a 4 year old female who presented to the ED with her mother on 11/2/15 at 10:34 am with vomiting and fever. She was triaged at 11:46 am, one hour and 16 minutes after presentation.

Patient C's MR described a 36 year old female who presented to the ED on 11/2/15 at 10:14 am with chest pain and shortness of breath (SOB). She was triaged at 10:43 am, 29 minutes after presentation.

The same lack of triage upon presentation to the ED was found in MRs of Patient E on 5/19/15 and Patient D on 8/16/15.

-- During interview on 11/4/15 at 1:00 pm with Staff #1, he/she acknowledged the above findings.

Findings pertaining to (2) above include:

-- Per review of the facility's policy and procedure (P&P) titled "Triage Policy Version 4," last revised 1/23/15, patients are triaged at levels 1-5 (1 being most acute). It directed nursing staff to triage patients with cardiac and respiratory distress as a level 1, sexual assault patients as a level 2 and patients with sudden onset of speech deficits or motor weakness should be triaged as a level 2.

-- However, per review of Patient C's MR, she presented to the ED on 11/2/15 at 10:14 am, with complaints of chest pain and shortness of breath; she was triaged as a level 3.

Patient E's MR revealed the patient presented to the ED on 5/19/15 at 4:54 pm, with a sexual assault and was triaged at a level 3.

Patient F's MR revealed a 63 year old male presented to the ED on 6/3/15 at 7:45 pm with stroke symptoms (e.g., right sided facial numbness and slurred speech). He was triaged at a level 3.

-- During interview on 11/4/15 at 1:15 pm, with Staff #1, he/she acknowledged the above findings.

Findings pertaining to (3) above include:

-- During tour of the ED on 11/2/15, it was noted that the facility did not post any notices outlining the rights of all patients in compliance with the Emergency Medical Treatment and Labor Act in the ED (i.e., entrance, admitting area, waiting room, treatment areas, etc).

-- The above findings were acknowledged by Staff #3 during the tour of the ED on 11/2/15.

Based on findings from document review, interview and observation, the emergency department (ED) policy and procedures (P&P) for sexual assault lacked information regarding post exposure prophylaxis (PEP), billing practices and follow up care as required by NYS Public Health Law, Chapter 39, Section 1, Paragraph c of subdivision 1 of section 2805-i, effective November 27, 2012. Also in 1 of 1 MR reviewed of a sexual assault patient, staff did not arrange a follow medical care appointment. Additionally the facility lacked a P&P regarding the release of locked 4 or 5 point restraints in an emergent situation, e.g., a patient who is vomiting or coughing and in danger of aspiration.

Findings include:

-- Per review of facility P&Ps titled "Genital Examination 1" publish date 5/13/15, and "Forensic Examination 1" publish date 5/21/15, they did not require hospital staff to provide a victim of sexual assault with a seven (7) day starter pack of human immunodeficiency virus (HIV) PEP or to arrange for an appointment for medical follow-up related to HIV PEP. Further, the P&Ps did not require the hospital to provide information on assistance from the NYS Office of Victims Services (OVS) or advise the victim of a sexual assault, orally and in writing that he or she may decline to provide information regarding private health insurance benefits if he or she believes the provision of that information would substantially interfere with his or her personal privacy or safety.

-- Review of Patient E's medical record (MR) revealed the patient arrived at the emergency department (ED) at 4:54 pm with a chief complaint of sexual assault. The discharge instruction sheet did not include arrangement of an appointment for medical follow-up related to HIV PEP as required by NYS Public Health Law.

-- During interview with Staff #1 on 11/4/15 at 12:00 pm, the above findings were acknowledged.

-- During a tour of the ED on 11/2/15 at 11:30 am, 5 point lockable leather restraints were available for use on patients. Staff #3 indicated that lockable 4-5 point restraints are used in the ED.

-- Per interview with Staff #4 on 11/3/15 at 9:00 am, he/she was not aware of a protocol regarding removal of the locked restraints in case of an emergency. She indicated there is no quick release of the locks on the restraints. When a 4 or 5 point restraint is used each lock must be unlocked separately. The sitter has the one key to unlock all points of the restraint.

-- Review of facility P&P related to restraints did not provide evidence that the facility had established procedures for emergency release of locked restraints of a patient in extreme physical distress.

-- During interview with Staff #1 on 11/3/15 at 2:00 pm, the above findings were acknowledged.