The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MT SINAI HOSPITAL MEDICAL CENTER 15TH STREET AT CALIFORNIA CHICAGO, IL 60608 Jan. 21, 2016
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on document review and interview, it was determined the Hospital failed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure a patient who presented to the Emergency Department (ED) was captured in the ED Central log. (Refer to tag A 2405)

2. The Hospital failed to provide a medical screening examination. Refer to tag A 2406.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1 of 20 (Pt. #1) sampled patients, the Hospital failed to ensure a patient who presented to the Emergency Department (ED) was captured in the ED log.

Finding include:

1. Pt #1 was a [AGE] year old male who presented to the Emergency Department (ED) on 7/27/14 and was greeted at 6:32 AM with a complaint of chronic pain. The record of the presentation contained an account number and the "Greeter Assessment" was completed to include vital signs (B/P, pulse, respiration, temperature, and Oxygen at 98 %). The record did not include any additional documentation in regards to this visit.

2. On 1/20/16 at 1:15 PM the Unit Director of Emergency Department (E #4) presented the ED log for the date of 7/27/14. Pt#1 could not be found in this log.

3. On 1/20/16 at 1:20 PM E #4 stated there is no ED log policy, although the Hospital maintains an ED log. E #4 stated the patients are entered in the log after they are triaged. E #4 stated this is the reason why Pt. #1 could not be found in the log. On 1/21/16, at 11:30 AM after reexamining their ED log, E #4 stated that Pt. #1 should have been found in the log but did not know why once the log was archived Pt #1 was not included in the log.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on document review and interview, it was determined that for 1(Pt #1) of 20 sampled patients who presented in the Emergency Department (ED), the Hospital failed to provide a medical screening examination (MSE).


Finding include:

1. Policy entitled "Transfer of Patients from the Emergency Department" (Revised 6/2014) indicated "Procedure: 1. Medical Screening Examination: All individuals who come to the Emergency Department...will be provided the opportunity to receive a medical screening examination.... A mid-level provider or physician may perform the medical screening examination."

2 On 1/21/16 the The "Medical Staff Bylaws" (Revised 2013) and the Rules and Regulation (Revised 5/2012) were reviewed. These documents failed to designate or identify the qualified medical personnel who can provide the MSE, nor did it define who are the mid-level providers to perform the MSE in the ED, as stated in the policy.

3. Pt #1 was a [AGE] year old male (MDS) dated [DATE] at 6:35 AM with a complaint of chronic pain. A "Greeter Assessment" was completed that contained Pt #1's vital signs (temperature 37.3 Celsius, respirations 18, blood pressure 175/113, pulse 105 and pulse oximetry of 98%) and a past medical history of hypertension, and diabetes. No additional documentation was included in this chart for this visit. Subsequently, Pt #1 was not triaged nor received a medical screening examination (MSE).

The "Patient Audit Trail" for this visit (7/27/14) indicated Pt#1's reason for visit to the ED was "Body Pain". On 7/27/14 at 6:57 AM the audit reflects the status event was edited "Checked-In /Pre-Registered Canceled". This audit does not reflect the reason why it was canceled.

4. On 1/21/16 at approximately 9:42 AM the Emergency Department Chairman (MD #4) was interviewed. MD #4 stated it is the expectation that every patient that presents to the ED is seen by a physician and/or midlevel provider for a medical screening examination (MSE) to determine the process to follow for the treatment of the patient.

5. On 1/21/16 at 10:00 AM the Director of the Emergency Department (E #4) was interviewed. E #4 stated the staff is also required to document the attempts of when the patient was called to be triaged. E #4 stated the staff are also required to document if the patient left without being seen. E #4 stated the staff failed to document what happened to this patient after he was greeted.