HospitalInspections.org

Based on review of medical records (MRs), review of facility documents and interview with facility staff (S) it was determined that the facility failed to ensure the privacy of all patients (0142); that all patients presenting to the Emergency Department (ED) are screened and assessed for suicide risk, and failed to implement their Suspected Victims of Abuse/Neglect/Exploitation policy by not notifying law enforcement about two minor patients that presented to the Emergency Department (ED) with suspected abuse (A0144). This failure resulted in an Immediate Jeopardy, posing a serious risk of harm to the patients.

The Immediate Jeopardy (IJ) was identified on 12/4/23 at 5:10 PM. An acceptable removal plan was received on 12/5/23 at 11:51 AM. Verification of implementation of the removal plan was conducted to include: a tour of the ED to observe the updated algorithm and tool kit documents at the nurse's station. Interviews with five registered nurses, two providers, and one social worker, confirmed staff education on the updated algorithm and tool kit documents. Facility staff were able to speak to the communication process for any suspected abuse, to include resource staff and materials.The IJ was lifted on 12/5/23 at 12:35 PM.

Cross Reference:
482.13(c) Patient Rights: Privacy and Safety
482.13(c)(2) Patient Rights: Care in Safe Setting

Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure that privacy requirements were met for one patient (P9) in accordance with facility policy.

Findings include:

Facility policy titled, "Authorization for the Use of Photography, Videotaping & Audio Recording" effective date 3/23, stated, " ...Workforce ...It is recognized that many mobile devices (i.e. cell phones, tablets, etc.) have photographic, video and audio recording capabilities, but the use of these features are prohibited by HMH team members unless authorization is granted and secured applications are embedded in a device. Note: Epic's mobile apps Haiku ...provide secure access for clinicians to Epic's electronic medical record. These applications can be utilized for secure capture of clinical images as outlined in the Documentation of Patient Care Section of this policy. ... Documentation of Patient Care. .... Photographs that are used to document in the patient's medical record must be recorded on an approved device ..."

On 12/4/23 at 10:45 AM, review of the Department of Emergency Medicine Quality Action Committee Meeting Minutes Date: November 16, 2023, revealed P9's case was reviewed, and the facility identified, "Standard of Care: Not Met Review: ...Provider used personal phone to take pictures. ...Action: ED looking to obtain a HMH [Hackensack Meridian Health] issued device for taking pictures to upload to EPIC ...."

On 12/4/23 at 11:45 AM, P9's medical record review was conducted with S9, the ED (Emergency Department Clinical Nurse Educator and S10, a Quality Improvement Specialist, and revealed: P9 presented to the ED on 9/29/23 at 9:44 PM with a chief complaint of "Vaginal Bleeding- 7 Years or Less" and was assigned an ESI 3 (Emergency Severity Index) [an algorithm to categorize patients from level 1, the most critically ill to level 5, the least critically ill and the least resource intensive].

The ED Provider Note on 9/29/23 at 11:45 PM stated, "Spoke with parents about getting photos of the vulvar area to place on the chart. ... Difficult exam, as previously, as the patient is fighting with the staff and trying to keep her legs closed." The medical record revealed four photographs of P9's vulvar and anus area were scanned into the medical record on 9/29/23: Photo Number 1 at 11:46 PM; Photo Number 2 at 11:47 PM; Photo Number 3 at 11:49 PM; and Photo Number 4 at 11:50 PM.

On 12/4/23 at 12:11 PM, upon interview with S9, he/she stated that the facility uses the "Haiku app [application]" that allows providers to take pictures that do not violate HIPPA (Health Insurance Portability and Accountability Act). S9 and S10 both confirmed they were unsure if the app is utilized from a provider's personal phone or from a facility phone.

On 12/4/23 at 1:42 PM, upon interview with S1, the Director of Patient Safety and Quality, he/she indicated that Haiku is an Epic [electronic medical record system] app [application] that directly uploads pictures within the app and does not save to the user's phone. S1 confirmed that the pictures taken in P9's medical record were uploaded from the Haiku app, however the app was utilized from the provider's personal cellphone. S1 stated, "now there are facility phones to take patient pictures with, there is one in the ED, one in the nursing supervisors' office and the wound care team has one."

A tour of the ED was conducted on 12/4/23 at 1:55 PM, with S7, the ED Nurse Manager, and S1. At 2:12 PM, an interview was conducted with S16, Psychiatric Advanced Practice Nurse (APN), that indicated that he/she hasn't taken any patient pictures, however was unaware of an app to use or a facility phone. At 2:16 PM, an interview was conducted with S17, an ED physician, who indicated that if a picture of a patient needs to be documented he/she uses the Haiku app on his/her personal phone. He/She was able to verbalize the process using Haiku. At 2:24 PM, S9 indicated that he/she was unaware of a facility phone in the ED for obtaining patient pictures. At 2:55 PM, an interview was conducted with S22, an ED Provider, who indicated that he/she takes patient photographs on the Epic Haiku app on his/her personal phone.

On 12/4/23 at 3:05 PM, S1 stated, "All providers were notified by email from the Chairman and Medical Director of the ED to not use personal phones for pictures of patients." A request was made for the email from the Medical Director to the ED providers. The email was received and reviewed. S1, also explained that a facility issued cell phone was allocated to the ED, to obtain photos of patients, if necessary.

On 12/5/23 at 11:01 AM, S1 confirmed that staff should only be using the facility phone to obtain photographs of patients. S1 also confirmed that the photographs obtained of P9 were from the ED providers personal phone through the "Epic Haiku app". S1 provided an email dated 12/4/23 at 8:03 PM from the Chair and Medical Director that stated, "If you are using the Epic Haiku app to take and upload pictures, that is an encrypted app that will not save the pictures onto your phone. That is an acceptable way to take pictures. Do no take pictures with your camera app and then upload the pictures." At 12:15 PM, the Chair and Medical Director sent another email to all the facility providers that stated, " ...The only way to use a phone to take pictures of a patient's physical finding to upload to Epic or to send to a consultant, is to use the Epic Haiku app on an HMH approved phone. We have one of these phones in the ANMs [Assistant Nurse Manager] office at each campus. If you need to take a picture of the patient, aske [sic] the ANM for this phone. Do not use your personal phone even if you have the Epic Haiku app on it. The HMH policy on this states that the phone must be an approved device and that is why this has been provided."

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to 1.) ensure that all patients that enter the Emergency Department (ED) are screened and assessed for suicide risk for one pediatric patient (#11); and 2.) implement their Suspected Victims of Abuse/Neglect/Exploitation policy by failing to notify law enforcement concerning two minor patients (#9 and #11) that presented to the Emergency Department (ED) with suspected abuse.

Findings include:

1. On 12/4/23 at 11:52 AM, upon review of Patient 11's (P11) medical record, in the presence of Staff 7 (S7), the ED Manager, it was revealed that each of these patients did not receive suicide screening during triage in the ED.

The facility policy titled, "Suicide Risk Screening, Assessment and Prevention Process" (dated 1/22) stated, " ... D. Procedure: 1. Emergency Department All patients eight years old and above presenting to the Emergency Department or Pediatric Emergency Department will be screened and assessed for suicide risk ... A. ADULT ... All patients 18 years old and greater after arrival to emergency department will be screened for suicide using the Patient Safety Screener 3 (PSS3) [a validated tool used to screen adult patients for suicide, and determine the need for further mental health evaluation, age 18 years and older] .... All patients 8 thru 17 years old after arrival to emergency department will be screened for suicide using the Ask Suicide-Screening Questions (ASQ [a validated tool used to screen pediatric patients for suicide, and determine the need for further mental health evaluation, age 8-17]."

On 12/4/23 at 11:25 AM, upon interview, S9 (ED Clinical Nurse Educator) indicated that every patient between the ages of 8 and 17 presenting to the ED receives an ASQ, and confirmed that P11 (fifteen-years-old) did not have the ASQ documented in the medical record.

On 12/4/23 at 11:56 AM, upon interview with S7 it was stated that every adult patient gets screened using the PSS3, and the pediatric patients are screened using the ASQ.

At 1:55 PM, upon interview with S11, the ED EPS (Emergency Psychiatric Services) Manager, he/she confirmed that all patients, no matter the complaint, physical or psychosocial should have a suicide screening during triage.


2. On 12/4/23 at 11:11 AM, upon review of P9 and P11's medical records, in the presence of S9 (ED Clinical Nurse Educator), and S10 (Quality Improvement Specialist), it was revealed that the police department was not contacted for each of these suspected cases of abuse, as follows:

On 9/29/23 at 9:44 PM, P9 (five-years-old), presented in the ED accompanied by his/her parents with a chief complaint of vaginal bleeding. The nursing assessment was completed, the provider was notified, and the Registered Nurse (RN) S12 notified DCP&P (Division of Child Protection and Permanency).

The ED Note dated 9/30/23 at 12:04 AM, indicated that "CPS (Child Protective Services, a.k.a. DCP&P) did not advise to not discharge the patient.... Due to the nature of the injury, child protective services was notified of the incident, and they will investigate further. ..." P9 was discharged home on 9/30/23 at 12:28 AM with parents. At 5:54 AM, S12 documented, "CPS to do further investigation." P9's medical record lacked documentation of police notification.

On 11/29/23 at 1:16 PM, P11 (fifteen-years-old) presented to the ED via ambulance with a chief complaint of Suicidal Ideation. The EMS (Emergency Medical Services) report noted that 911 call was initiated by an anonymous caller, indicating P11 was being abused by his/her mother. The provider was notified, and DCP&P was notified. At 8:56 PM, the ED Note documented by S13, indicated "waiting for CPS." P11's Discharge Disposition dated 11/29/23 at 10:20 PM stated, "Discharge to mom, follow up with DCP&P tomorrow." The minor was discharged to home with mother. P11's medical record lacked documentation of police notification.

Review of facility policy titled, "Suspected Victims of Abuse/Neglect/Exploitation, 1510" dated 7/20, stated, " ... A person having reasonable cause to believe that a child has been subjected to abuse or acts of abuse should immediately report this information to the State Central Registry (SCR) at [phone number]. If the child is in immediate danger, call 911 ..."

On 12/4/23 at 12:11 PM, upon interview with S9, he/she indicated that if a child presents with suspected physical or sexual abuse, under 18 years old, DCP&P would be notified, also the police department in the town that the incident occurred.

On 12/4/23 at 2:15 PM, upon interview with S19 (ED RN), it was stated that for suspected physical or sexual abuse on a child, first, they would let a provider know. S19 further stated that both physicians and nurses may call, however the police department and DCP&P will be notified.

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that the facility policy and procedure was implemented for Medical Screening Exams (MSEs) for one patient (#1).

Findings include:

On 12/4/23 at 10:05 AM, a review of Patient 1 (P1) medical record was conducted in the presence of Staff 4 (S4) (ED Assistant Nurse Manager), and revealed that on 11/29/23:

At 11:48 PM, P1 arrived at the facility ED with a Chief Complaint of "Homeless, Denies chest pain. Verbalizes [he/she] is tired. No shortness of breath.
At 11:56 PM, P1's vital signs were taken.
At 11:57 PM, P1 was screened for Suicidal Ideation (SI) with the PSS3 (Patient Safety Screener 3). P1 was screened with three questions: "1. In the past two weeks, have you felt down, depressed, or hopeless? No. 2. In the past two weeks, have you had thoughts of killing yourself? No. In your lifetime, have you ever attempted to kill yourself? No." The bottom of the PSS3 flowsheet indicated "Suicide Screening Status: NEGATIVE SCREEN."
At 11:58 PM, P1 was assigned an Emergency Severity Index (ESI) 5 [on a scale of 1 to 5, ESI 1 is the most emergent level, requiring life-saving interventions].
At 12:10 AM, P1 was placed in an ED room.
At 1:29 AM, Registration was completed.
At 3:10 AM, Medical Screening Exam (MSE) was completed.

Review of the facility policy titled, "Emergency Medical Treatment And Labor Act (EMTALA) Policy" (dated 2/23) state, " ... The hospital shall not seek, or ask the patient to seek, authorization from the patient's insurance company for screening or stabilizing purposes until after the Hospital has provided an appropriate Medical Screening Examination ... "