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.

ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL SOMERSET 110 REHILL AVE SOMERVILLE, NJ 08876 March 22, 2011
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
A EMTALA survey was conducted at Somerset Medical Center, March 16, 17, 18, 21 and 22, 2011.

29 Medical Records reviewed
Staff interviewed
Documentation reviewed

Somerset Medical Center is not in compliance with the requirements of 42 CFR Part 489 Appendix V requirements for Hospitals EMTALA regulations.

MR-Medical Record
L&D-Labor and Delivery
ED-Emergency Department
IMCU-Intensive Medical Care Unit
PAs-Physicians Assistants
APNs-Advanced Practice Nurses
MSE-Medical Screening Exam
PESS-Psychiatric Emergency Screening Services
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on a review of the ED Log and a review of 29 medical records, it was determined that the log entries for 8 of the 29 medical records (MR #7, #19, #3, #20, #30, #8, #16, #23) reviewed contained inaccurate information. The facility failed to ensure that ED Log entries were accurate.

Findings include:

1. MR #7 documented the disposition of the patient as discharged . The ED log documented the disposition of the patient as transferred.

2. MR #19 documented the disposition of the patient as discharged . The ED log documented the disposition of the patient as L&D.

3. MR #3 documented the disposition of the patient as transferred. The ED log documented the disposition of the patient as home.

4. MR #20 documented the disposition of the patient as transferred. The ED log documented the disposition of the patient as home.

5. MR #30 documented the disposition of the patient as transferred. The ED log documented the disposition of the patient as home.

6. MR #8 documented the disposition of the patient as admitted to IMCU. The ED log documented the disposition of the patient as "1:1/2."

7. MR #16 documented the disposition of the patient as discharged back to rehabilitation. The corresponding ED log documented the disposition of the patient as transferred.

8. MR #23 documented the disposition of the patient as discharged . The ED log documented the disposition of the patient as transferred.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on a review of the Somerset Medical Center's Medical and Dental Staff Bylaws, review of the ED Staff Roster, review of Somerset Medical Center Policy #1002; EMTALA (Effective Date 1/9/07) and Staff interview, it was determined that the facility failed to ensure that all patients seeking care at the ED were provided a MSE by Qualified Medical Personnel.

Findings include:

1. The Somerset Medical Center Medical and Dental Staff Bylaws (Adopted 1/1/03), were reviewed at 9:30AM on 3/18/11 and revealed the following:

a. No evidence was found regarding a definition of Qualified Medical Personnel in the Bylaws.

b. No evidence was found regarding the roles and responsibilities of PAs or APNs in the Bylaws.

c. Per Somerset Medical Center Policy #1002; EMTALA, Qualified Medical Personnel is defined as, "for the purpose of a medical screening examination a 'qualified medical person' is a credentialed physician on staff at Somerset Medical Center operating within their scope of practice."

d. Per interview with Staff #1, on 3/18/11 at 10:20AM, an APN is employed in the ED and performs MSEs on patients. Staff #1 added that several PAs are employed in the ED and perform MSEs on patients.

e. When asked to produce a list of ED patients that had an APN or PA perform the MSE (for the last 30 days), Staff #1 presented a list from 2/11/11- 3/12/11, which contained 1,668 patients. It was confirmed by Staff #1 that these patients were not provided a MSE by a Qualified Medical Personnel, as defined by the Bylaws and facility Policy and Procedure.

2. Review of MR #3 revealed the following:

a. The Patient came to the ED for Suicidal Ideations (no plan) at 1409 on 3/2/11. Documentation in the medical record indicated that the patient was medically cleared for PESS at 2022 on 3/2/11.

b. The following was documented on the PESS Crisis Team Evaluation form, dated 3/3/11:

i. The patient had a long history of psychiatric inpatient hospitalization s, with several previous suicide attempts by overdose. The patient told the psychiatric screener, "... I've bee (sic) having thoughts to hurt myself but also ayt (sic) times other people."

ii. "Writer [the screener] asked patient if inpatient treatment is recommended would she (sic) be voluntary and Pt replied 'Yes.' "

iii. "Patient has made no attempts to get any outpatient treatment."

iv. "The patient had 4 inpatient hospitalization s within 6 months of this admission, 2 for suicidal ideations, 1 for suicidal ideations; alcohol abuse, and 1 for depression and the patient denied any treatment, and stated that he had not been taking his medications."

v. "Treatment Recommendation/Least Restrictive Alternative: Based on Pt's Clinical Presentation: SI with no Plan; No HI [homicidal ideations]/Intent/Plan; decreased Depression; Increased Anxiety; Poor Thought process(racing thoughts); Drug Abuse (Cocaine); Isolation; Flat Affect; Labile Mood; Fair Insight; Poor Judgement, patient needs Inpatient hospitalization for safety and stabilization. Patient is voluntary for admission."

vi. "Disposition: d/c"

c. The following was documented in the PESS Crisis Team Evaluation Progress Notes:

i. 3/3/11 at 7:19AM - "Writer [screener] called 5 West [the inpatient psychiatric unit of this facility] to see if they have any beds. Writer was informed that they have 2 beds. GR. [author's initials]."

ii. 3/3/11 at 10:10AM "... 1. Pt. is voluntary and referred to 5 West 2. Updated mental status needs to be done as the Pt. frequently comes in when he has housing issues."

iii. 3/3/11 at 11:22AM - "Dr. H____ is denying pt from 5 West, based on believing that Pt. requires a higher level of care- reported by Tracy. -JKS."

iv. 3/3/11 at 12:13PM - "Pt requires hospitalization and pt's symptoms have increased. Pt now has a suicide plan and auditory hallucinations. Pt is agreeable to be referred to _____ [facility] if they have a bed.-JKS."

v. 3/4/11 at 9:30AM - "Writer spoke with patient who states that he is feeling better and does not want to go inpatient any more. Patient is requesting to speak with the psychiatrist about being discharged . KC."

vi. 3/4/11 at 9:30AM- "Writer reviewed case with supervisors. Patient is appropriate for discharge. KC."

vii. 3/4/11 at 10:30AM - "Writer reviewed discharge instructions with patient. Patient verbalized understanding and signed. KC."

viii. 3/4/11 at 10:50AM - "Patient was discharged by RN KC."

d. No evidence was found in MR #3 that a physician made the determination that the patient's EMC had resolved.

e. No evidence was found in MR #3 that a physician had ordered the patient's discharge.

3. Review of MR #30 revealed no evidence of a physician's order to admit the patient.

4. Review of MR #20 revealed no evidence of a physician's order to discharge the patient.

5. Review of MR #7 revealed no evidence of a physician's order to discharge the patient.

6. Review of MR #19 revealed no evidence of a physician's order to discharge the patient.




B. Based on review of a medical record (MR#1) of a patient who (MDS) dated [DATE] and 3/8/11, it was determined that not all patients were provided with an appropriate medical screening examination to determine whether or not an emergency medical condition existed.

Findings include:

REFERENCE: Facility Policy, "Wet Reading Policy," states "Exams requested with a Wet Reading will be read as soon as completed and the results called to the requesting physician..." The policy continues to state under Procedure: Out Patient Wet Reading requests, "...When the exam is completed the patient is asked to remain in the waiting room until their doctor has been notified of the results. A Wet Read form is filled out and taken to a Radiologist for an immediate interpretation of the x-rays. One this is done a phone call is placed to the ordering physician and the results are given and documented..."

1. On 3/6/11, Patient #1 presented to the ED at 3:54 PM from a group home with a complaint of vomiting, diarrhea, and abdominal pain since the morning. The patient's past medical history includes, but is not limited to sleep apnea, cholecystectomy, appendectomy, eye surgery, and small bowel obstruction. The patient's pain level was documented as, "7/10." An evaluation was completed by the physician at 4:20 PM and lab work was ordered. There was no evidence in the medical record of any other tests ordered. The patient was discharged back to the group home at 9:41 PM with instructions to follow up with the Family Practice office in two days.

2. On 3/8/11, the patient was seen at the Family Practice Office, with continued complaints of nausea/vomiting and abdominal pain of 8/10. The patient was referred back to the ED and an order was written at 4:30 PM for an X-Ray Abdominal Series and lab work and to page Dr. ______ with wet read.

3. According to MR#1, the X-Ray was completed at 6:12 PM. Documented on the X-Ray report under IMPRESSION, "Small bowel obstruction with portal air, a finding that suggests necrosis of the bowel. This was called to the emergency room at the time of reading and I was told the patient had expired." The statement under DISCUSSION stated, "Examination of the abdomen reveals gross small bowel obstruction with grossly dilated loops of small bowel. What appears to be portal air is seen. I noted the patient has had previous episodes of small bowel obstruction."

4. The "Wet Reading Policy" was not followed.

5. The results were not called to the requesting physician "as soon as completed."

6. The x-ray results were not called to the ED for at least 5 hours and 23 minutes after the X-Ray was taken.

7. According to the ED record, a "Code" was called at 23:02 (11:02 PM) and the patient expired at 11:35 PM on 3/8/11.

8. All of the above was confirmed by Staff #1.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on a review of 29 medical records, review of facility policy, and interview with facility staff, it was determined that the facility failed to ensure that all reasonable steps to secure the individual's written informed refusal of treatment was obtained. Medical record review revealed that 7 out of 7 medical records (MR #13, #15, #18, #22, #25, #26, #27) of patients that left the facility AMA, did not contain 'Form 21-125.'

Findings include:

Facility Policy Number: A10-20D1, Subject: PATIENTS LEAVING WITHOUT DISCHARGE (Against Medical Advice and/or Eloping), on page 2 of 7 under Procedure, states: RN Responsibilities, number 7. states "Have patient/guardian complete and sign Form 21-125, Release From Responsibility for Discharge, using a certified translator if needed." Number 8. states "RN signs the form as witness to the patient/guardian." Number 9. states "Form is placed in the medical record."

1. Review of MR #13 revealed that the medical record did not contain 'Form 21-125.'

2. Review of MR #15 revealed that the medical record did not contain 'Form 21-125.'

3. Review of MR #18 revealed that the medical record did not contain 'Form 21-125.'

4. Review of MR #22 revealed that the medical record did not contain 'Form 21-125.'

5. Review of MR #25 revealed that the medical record did not contain 'Form 21-125.'

6. Review of MR #26 revealed that the medical record did not contain 'Form 21-125.'

7. Review of MR #27 revealed that the medical record did not contain 'Form 21-125.'

8. All of the above was confirmed by Staff #13.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on review of 29 medical records, it was determined that the facility failed to ensure that all transfers were conducted per physician's orders. Six out of six medical records (MR #5, #6, #10, #17, #28, #29) of patients that were transferred, did not contain a physician's order to transfer.

Findings include:

1. Review of MR #5 revealed no evidence of a physician's order to transfer the patient.

2. Review of MR #10 revealed no evidence of a physician's order to transfer the patient.

3. Review of MR #6 revealed no evidence of a physician's order to transfer the patient.

4. Review of MR #17 revealed no evidence of a physician's order to transfer the patient.

5. Review of MR #28 revealed no evidence of a physician's order to transfer the patient.

6. Review of MR #29 revealed no evidence of a physician's order to transfer the patient.




B. Based on review of medical records (#12, #17, #28, #29), review of facility policies and an interview with facility staff, it was determined that the facility failed to ensure that all patients transferred to another facility were transferred as per facility policy.

Findings include:

REFERENCE: Facility Policy Number: 1002, Subject: Emergency Medical Screening and Active Labor Act, under Procedure, Number 13. states "All patients transferred to another facility must have the following documented on their chart...d. Inter-Facility transfer form including:..."

1. Documentation in MR #12 revealed the following:

a. A [AGE] year old female was brought to the ED on 12/8/10 at 9:06AM by ambulance, after being found unresponsive in her car, with a diagnoses of possible stroke. A stroke code was called and the patient was evaluated. A CT scan was completed at 9:29AM which showed " ...a diffuse subarachnoid hemorrhage. There is blood tracking along the tentorium. There is probably blood in the third ventricle." A repeat CT scan, completed at 3:08PM, showed "Again noted is a subarachnoid hemorrhage. Blood is seen layering along the tent and surrounding the cerebellum." At 5:15PM, as Somerset Medical Center is not a comprehensive stroke center the patient was transferred to another facility, which is a comprehensive stroke center.

b. The patient was brought to the Somerset Medical Center ED at 9:06AM and not transferred to the comprehensive stroke center until 5:15PM. This was 8 hours, 9 minutes from the time of arrival to the time of transfer.

c. There was no documentation stating the reason for the delay in transfer to the comprehensive stroke center.

d. There was no documentation in the medical record of a INTER-FACILITY TRANSFER FORM being completed.

2. Documentation in MR #17 revealed the following:

a. A [AGE] year old male was brought to the ED on 10/4/11 at 2:32AM via ambulance. The patient was found to be intoxicated and complaining of throat pain. The patient was in need of detoxification and in-patient treatment and was transferred to a Short Term Care Facility.

b. There was no evidence in MR #17 of a INTER-FACILITY TRANSFER FORM being completed.

3. Documentation in MR #28 revealed the following:

a. A [AGE] year old male was brought to the ED on 9/17/10 at 2:10PM via ambulance after falling off a bicycle. A CT scan revealed hepatic and splenic lacerations with hemorrhagic ascites. The patient was transferred to a trauma center for a higher level of care.

b. There was no evidence in MR #28 of a INTER-FACILITY TRANSFER FORM being completed.

4. Documentation in MR #29 revealed the following:

a. An 8 year old female was brought to the ED on 9/19/10 at 7:35PM by a family member with complaints of fever and nausea. Examination revealed an appendicitis.

b. The patient was transferred to another facility to be treated by a pediatric surgeon.

c. Staff #11 stated that there was no surgeon on call the night of 9/19/11, that could perform an appendectomy on an 8 year old.

d. There was no evidence in the medical record of a INTER-FACILITY TRANSFER FORM being completed.