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.

EAST ORANGE GENERAL HOSPITAL 300 CENTRAL AVE EAST ORANGE, NJ 07018 April 11, 2013
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on a tour of the ED and staff interview conducted on April 8, 2013 at approximately 10:30 AM, it was determined that the facility failed to conspicuously post signage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions and women in labor or information indicating whether or not the hospital participates in the Medicaid program.

Findings include:

1. Observation of the main entrance to the ED revealed only one sign pertaining to EMTALA law and information indicating whether or not the hospital participates in the Medicaid program which were inside of the building, between the two entrance doors (one for walk in patients and one for ambulance patients), which are approximately 10 feet apart. Neither the walk in patients or ambulance patients pass this sign en route to the ED.

2. Observation of the main ED waiting area revealed one sign pertaining to EMTALA law or information indicating whether or not the hospital participates in the Medicaid program posted under the television.

3. Observation of the fast track area revealed no signs pertaining to EMTALA law or information indicating whether or not the hospital participates in the Medicaid program posted.

4. Observation of the main ED treatment area revealed no signs posted pertaining to EMTALA law or information indicating whether or not the hospital participates in the Medicaid program.

5. Observation of the triage area revealed no signs posted pertaining to EMTALA law or information indicating whether or not the hospital participates in the Medicaid program.

6. All of the above findings were confirmed by Staff #3.
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on review of the ED log and 33 medical records, it was determined that the log entries, for 5 of 33 medical records (Medical Records #2, #3, #21, #22 and #23) reviewed, contained inaccurate information.

Findings include:

1. Review of the ED log for 10/10/12 indicated the disposition of Patient #2 as "Left without being seen." Review of Medical Record #2 indicated the patient was discharged home.

2. Review of the ED log for 3/20/13 indicated the disposition of Patient #3 as "Left without being seen." Review of Medical Record #3 indicated the patient eloped from the hospital.

3. Review of the ED log for 1/12/13 indicated the discharge time for Patient #21 as 3:32PM. Medical Record #21 indicated the discharge time for Patient #21 as 10:51AM.

4. Review of the ED log for 1/12/13 indicated the discharge time for Patient #22 as 10:00AM. Medical Record #22 indicated the discharge time for Patient #22 as 6:49AM.

5. Review of the ED log for 1/12/13 failed to state the time the physician saw the patient creating a gap in the log. Review of Medical Record #23 indicated the patient was seen by the physician at 8:33AM.

6. All of the above findings were confirmed by Staff #2.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview, and review of facility policies and procedures it was determined that the facility failed to provide stabilizing treatment to all patients.

Findings include:

Reference #1: Facility's Emergency Services Plan- Scope of Service states Emergency "[2nd paragraph] Services are available 24 hours a day, 7 days a week. We are prepared to provide initial assessment and immediate intervention, necessary treatment, stabilization, hospital admission or transfer if services required are not available here, or discharge with instruction and appropriate referral(s) for follow up care."

Reference #2: Facility policy and procedure Code No.: G001:45, titled 'TECHNOLOGISTS ON-CALL' states I. POLICY Technologists will be available on-call after hours for emergencies in the areas of Cat Scan, Nuclear Medicine, Ultrasound, and Diagnostic/Special Procedures. ... III. PROCEDURE: 1) ... The Technologists in each area are responsible for coverage 24 hours/day, 7 days/week and 52 weeks/year. ... At no time is the Technologist on-call to be unavailable. ... 3) Technologists are to respond immediately by phone to any pages and if necessary arrive at the hospital within 30 minutes."

Reference #3: Facility policy and procedure Code No.: 'Internal Process', titled 'Emergency Medical Treatment And Active Labor Act Requirements' states "... IV. PROCEDURE: I. Appropriate Medical Screening Examination (MSE) A. MSE Procedure- General. 1. When an individual comes to the hospital for emergency care, the hospital must provide the individual with an appropriate medical screening examination (MSE), within the capability of the ED (including ancillary services routinely available to the emergency department) to determine whether an emergency medical condition exists. ... 6. The MSE must be the same MSE that the hospital would perform on any individual coming to the hospital with the same signs and symptoms, ..."

1. On 4/2/13 at 10:10 AM the ED was toured in the presence of Staff #2 and Staff #3. Staff #5 was interviewed at 10:20 AM and he/she stated a high D-dimer can be indicative of a blood clot. Staff #5 added that on Saturdays they do have Ultrasound in the morning, but not vascular. Staff #5 discussed that if he/she suspected a pulmonary embolism he/she would possibly do a CT scan of the chest with intravenous contrast, anticoagulate (Lovenox, Soralto) the patient, normally admit the patient, but the patient can be discharged if stable and they can be anticoagulated at home. Staff #5 stated he/she has never discharged a patient home with follow up for an ultrasound.

a. Staff # 4 confirmed that vascular is not on call on weekends. He/she stated that he/she is not sure why this is.

b. Per Staff #5, it is rare that a patient is sent home from the ED with Lovenox injections.

c. Per Staff #6 at 10:30 AM, vascular is not on call on Saturday & Sunday for ultrasound procedures. Vascular is only available Monday thru Friday.

2. On 4/2/13 review of Medical Record #1 indicated the following:

a. Per an ambulance run sheet, Patient #1 arrived to the ED on 1/12/13 2249.

b. Patient #1 was triaged at 2321 as a level 4 with complaints of left leg pain.

c. The Medical Screening Exam (MSE) was performed by a Physician's Assistant (PA) at 23:44. The MSE indicated the patient complained of sharp pain that radiates from his/her lower left leg to thigh area, and that the patient stated he/she noticed swelling behind his/her left knee with pain days ago.

d. D-dimer level was high at 1130 (208-599).

e. A PA note at 02:15 AM indicated Patient #1 declined Lovenox [anticoagulant] injection, and that the patient stated he/she would rather have an ultrasound at --[name of another local hospital]-- to verify if he/she has a deep vein thrombosis (DVT) before taking the medication. The PA's note indicates he/she discussed the case with the ED attending physician.

f. Discharge instructions directed Patient #1 to follow up the following Monday for an ultrasound and to take Lovenox injections twice daily.

g. The Discharge Assessment Flow Sheet timed 02:10 indicates Patient #1 left the ED in stable condition.

3. The ED was toured a second time on 4/2/13 at 12:00 PM in the presence of Staff #2 and Staff #3. Staff #5 reviewed Medical Record #1 and confirmed that Patient #1 refused Lovenox. Staff #5 stated that ultrasound really is the best test for DVT in the leg, and that the PA chose his/her best option to treat with Lovenox until the ultrasound could be done.

a. Staff #8 was the treating PA and was able to review Medical Record #1 again at this time. Staff #8 stated that on weekends there is no ultrasound for vascular, and vascular is also not available for ultrasound after normal business hours. Staff #8 stated Patient #1 was stable for discharge because he/she was walking, and that the prescribed Lovenox would be prophylactic because the facility did not have ultrasound for vascular study.

4. On 4/2/13 at 10:55 AM the 'TECHNOLOGISTS ON-CALL' policy and procedure provided by Staff #6 was reviewed. Per the policy, the technicians are supposed to be on call 24/7. The on call schedule for January 2013 was also reviewed and an ultrasound technician was listed as on call for each day of the month.

a. Per Staff #6, this policy and procedure does not apply to or include vascular technicians.

b. Staff #6 stated in interview at 11:47 AM that the former medical director of the vascular lab, in this position from 2007 until July 2012, changed the on call to no vascular on call, and to treat the patients via anticoagulant therapy until the ultrasound study can be done, when vascular is available, Monday thru Friday 8:30 AM-6 PM. Staff #6 stated there was a memo sent at the time, but he/she cannot find it. There was also a policy, regarding the same, but he/she cannot find it.

c. Staff #6 stated if there is an emergent need for an ultrasound, they [facility/ED staff] can call him/her and he/she can call the ultrasound technician in to do the vascular ultrasound. Staff #6 stated all of the ultrasound technicians can do vascular studies.

5. The facility did not have ultrasound services available 24/7 per their policy, in reference #2. The facility could not provide Patient #1 with a needed vascular ultrasound at the time of his/her ED visit, and instructed him/her to return the following Monday for the ultrasound test.

a. The facility was not prepared to provide the necessary immediate intervention, and necessary treatment, the ultrasound testing, as per reference #1, for Patient #1 to complete his/her medical screening exam (MSE).

6. Per review of a medical record for Patient #1 obtained on 4/4/13 from another acute care facility, Patient #1 arrived at the other facility on 1/13/13 at 02:38. An ultrasound of the patient's left leg was completed to rule out deep vein thrombosis.

7. On 4/9/13 Medical Record #31 was reviewed and indicated the following:

a. Patient #31 arrived to the ED on 10/1/12 at 3:05 PM. Per the Triage notes, the patient's chief complaint was "patient sent by doctor for chest pain and leg pain."

b. The patient was medically evaluated by the physician at 1515, and the patient reported right lower extremity calf pain. Per the medical exam, the patient had tenderness to the right calf without [DIAGNOSES REDACTED], warmth, or edema. A venous doppler was ordered.

c. A venous doppler report dated 10/1/12 indicated a lower extremity venous duplex was completed for Patient #31, and was negative for the patient's right and left legs.

8. Patient #31 presented to the ED with similar complaints as Patient #1. Patient #31 was provided with a venous doppler study, but patient #1 was asked to return to the facility on another day for an ultrasound. The facility was not consistent in its treatment and evaluation of patients that present with same signs and symptoms, as per reference #3.