HospitalInspections.org

Based on document review and interview, in 1(one) of 30 sampled cases reviewed, the facility did not implement its policy to ensure that the central log was kept accurate, complete, and contained information for each patient who presents to the Emergency Department (ED) for care (Patient #1).

This failure prevents the tracking of the care provided to each patient who presents to the facility seeking care in the Emergency Department.


Findings are:

The review of document titled "Greeter Form" revealed Patient #1 arrived in the Emergency Department at 4:55 AM with complaint of "vaginal bleed/spotting." The form was signed by a Registered Nurse but not dated.

At interview with Staff A on 3/10/16 at 10:00 AM, confirmed that Patient #1 was brought to the ED by EMS ambulance sometime on 3/3/16 with a chief complaint of spotting and vaginal bleeding.

The facility did not implement its policy titled "Triage Emergency Index (ESI)," last reviewed on 3/2016. The policy notes that pregnant women arriving ambulatory or by EMS will have a registration performed, and be logged into the ED central log.

Review of the ED Log covering eight months period from August 2015 to March 2016 revealed the log did not contain information on Patient #1; the name of the patient, the reason for the visit and her disposition was not entered into the log.

At interview with Staff A on 3/10/16 at approximately 11:00 AM, she acknowledged the patient's ED encounter was not documented in the ED log.

Based on document review and interview, in 1 of 30 sampled cases reviewed, the facility did not implement its policy to ensure that each individual presenting for care in the Emergency Department (ED), received appropriate Medical Screening Examination (MSE) to determine the existence of an Emergency Medical Condition (Patient #1).

This failure placed the patient at potential risk for delay recognition and treatment of her medical condition.


Findings include:

The review of document titled "Greeter Form" revealed Patient #1 arrived in the Emergency Department at 4:55 AM with complaint of "vaginal bleed/spotting." The form was signed by a Registered Nurse but not dated.

The facility did not implement its policy and procedure titled, "Triage Emergency Severity Index (ESI)" last reviewed on 3/2016. The policy notes, "Every person arriving at the emergency department for care shall be promptly examined, diagnosed, and appropriately treated ... women who arrive ambulatory or by EMS will receive a rapid triage screen and provided medical screening examination. The patient will be rendered stabilizing treatment."

There was no evidence of a medical screening examination and treatment provided to Patient #1 prior to her transfer to another facility.

At interview with Staff A on 3/10/16 at 10:00 AM, she stated, "I did not Triage the patient. The patient was at the Ambulance Bay Triage Area, in the EMS stretcher, with two EMS Technicians. She reported that she saw Staff B, ED Manager and Staff D, ED Attending Physician having a discussion while she was in Triage and could not recollect if Staff D evaluated the patient. She stated, "I initiated the 'Greeter Form' and left the form on the Triage table while I continued triaging other patients. After 30 to 40 minutes, I saw them (EMS) pushing the patient out from the ED."

At interview with Staff D on 3/10/16 at 2:30 PM, ED Attending Physician, he stated that he was made aware of the patient's arrival in the ED by Staff #A, the ED Triage Nurse. He stated that the facility does not provide obstetrical services and that the patient needed to be transferred to a hospital that has labor and delivery services. He confirmed that he did not conduct a medical screening examination and did not determined if an emergency condition existed. Staff D stated that he communicated with EMS personnel about other hospitals capable of Labor and Delivery services.

At interview with Staff B, ED Nurse Manager on 3/10/16 at approximately 11:00 AM, she stated, "I was called by the Triage Nurse who reported an 8½ month pregnant woman in the ED. I saw Staff D at the foot of the patient's stretcher talking with the patient in the presence of EMS technicians." Staff B confirmed that the patient did not receive a medical screening examination. She added that she did not know where EMS eventually took the patient.

Based on document review and interview, the facility failed to implement its policy to ensure that an appropriate transfer was effected for a woman who presented to the ED, 8½ months pregnant with complaints of vaginal bleeding/spotting and reported a ruptured membrane. This finding was evident in one (1) of 30 sampled patient records reviewed (Patient #1).

This failure to implement an appropriate transfer placed patient at risk for potential harm.


Findings include:

The review of document titled "Greeter Form" notes, Patient #1 arrived in the Emergency Department by EMS ambulance at 4:55 AM with complaint of "vaginal bleed/spotting." The form was signed by a Registered nurse but was not dated.


There was no documented evidence that an appropriate transfer was effected for Patient #1 in accordance with the facility's policy and procedure titled, "Inter- Facility Transfer of Patients" last reviewed on 3/2016. The policy notes the following:
"Transferring out Patients to other Acute Care Facilities: The Mount Sinai (MS) physician shall contact the physician at the receiving facility and provide pertinent data on the patient. The facility must confirm space, and qualified personnel to provide treatment and agree to accept the transfer;"
"The MS ED RN shall contact the RN at the receiving facility and give nursing report;"
"A Physician's Certificate and Patient consent FOR Transfer Form and Inter-Hospital Transfer Form must be completed for all patients transferred from the hospital;"
"A copy of the medical record with available data is sent with the patient..."

At interview with Staff #D, the ED Attending Physician on 3/10/16 at 2:30 PM, stated that he was made aware of the patient's arrival in the ED on 3/3/16 by Staff A, the ED Triage Nurse. He stated the following: the facility does not provide obstetrical services; the patient needed to be transferred to a hospital that has labor and delivery services; he did not examine the patient but determined the patient's membranes had ruptured based on the patient's stated history; he did not call any physician at the "receiving hospital, but communicated with EMS personnel about other hospitals capable of Labor and Delivery services; he did not arrange the transfer to the receiving hospital.