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.

JEFFERSON STRATFORD HOSPITAL 18 EAST LAUREL ROAD STRATFORD, NJ 08084 July 28, 2017
VIOLATION: POSTING OF SIGNS Tag No: A2402
Based on observation, review of facility policy and procedure, and staff interview, it was determined that the facility failed to conspicuously post signage, specifying the rights of individuals under section 1866 of the Act with respect to examination and treatment of emergency medical conditions and women in labor.

Findings include:

Reference: Facility policy, Signage Meeting Regulatory Standards (EMTALA), states, "... 2. Location of the signage is as follows: Lobby, Admissions, All public entrances, ED waiting area, ED Triage Room, Labor and Delivery Rooms ..."

1. A tour of the Washington Township Division, conducted on July 21, 2017, revealed that there were no EMTALA signs posted in the following areas:

a. Hospital main entrance/Lobby

b. ED entrance

c. ED ambulance entrance

d. ED triage area

e. ED Intake Rooms #1 through #4

f. ED Medical Screening Area #1 and #2

g. ED Acute Results Waiting Lounge #2

h. ED Acute Room #15

i. ED Subacute Room #24

j. ED Acute Hallway Areas #1 through #10

k. Labor and Delivery Triage Hallway #79 and #80

2. A tour of the Washington Township Division, conducted on July 21, 2017, revealed that the EMTALA signs posted in the following areas were not visible to patients and visitors:

a. Results Waiting Area

b. Labor Room #73

3. These findings were confirmed by staff #1 and Staff #2.




4. A tour of the Stratford Division, conducted on July 25, 2017, revealed that there were no EMTALA signs posted in the following areas:

a. Hospital main entrance/Lobby

i. The above was confirmed with Staff #4 and Staff #13.

b. ED Intake/Pivot room

c. ED Triage area

d. Results Waiting (recliner area)

e. ED Room #3, #4, #7, #8, #10, and #11

f. ED Hallway stretcher #1, #2, and #4

g. ED Ready Room area #1

h. ED Satellite area A, B, C, and D

i. ED Express area A, B, C, and D

j. Observation room(s) on non-designated units throughout the facility

i. The above was confirmed with Staff #2.

5. A tour of the Stafford Division, conducted on July 25, 2017, revealed that the EMTALA signs posted in the following areas were not visible to the patients:

a. ED entrance

b. ED Ready Room areas #2, #3, and #4

6. The above findings were confirmed by Staff #2, and Staff #23.

7. A tour of the Cherry Hill Division, conducted on July 27, 2017, revealed that there were no EMTALA signs posted in the following areas:

a. The Garage and Surface parking entrance

i. The above was confirmed with Staff #2, Staff #5, and Staff #13.

b. Hospital main entrance

i. The above was confirmed with Staff #2, Staff #5, and Staff #13.

c. ED Triage Rooms #1 and #2

d. ED Trauma area A and B

e. ED ECG (Electrocardiogram) wait and treatment room

f. ED Rooms #1 through #12

g. ED Results Pending (recliner area)

h. ED Express Care area A, B and C

i. ED Treatment Rooms #14, #16, #17, and #18

j. Observation room(s) on non-designated units throughout the facility

i. The above was confirmed with Staff #2.

8. A tour of the Cherry Hill Division, conducted on July 27, 2017, revealed that the EMTALA signs posted in the following areas were not visible to patients and visitors:

a. ED entrance

b. ED Treatment Room #15

9. The above findings were confirmed by Staff #2, Staff #40 and Staff #41.
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
Based on a review of the ED on-call schedule for the Washington Township Division and staff interview on July 24, 2017, it was determined that the facility failed to ensure that written policies and procedures are in place to respond to situations in which a particular specialty is not available.

Findings include:

1. Review of the Department of Surgery on-call schedule, revealed the following:

a. There was no coverage for Thoracic surgery on 5/20/17, 5/27/17, 5/28/17, 5/29/17, 6/3/17, 6/4/17, 6/16/17, 6/17/17, 6/18/17, 7/1/17, 7/2/17, 7/4/17, 7/8/17, and 7/9/17.

2. Upon request, Staff #1 was unable to produce written policies and procedures that respond to situations in which a particular specialty is not available.

3. The above findings were confirmed by Staff #1.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on review of the facility document titled, "Medical Staff Code of Conduct Rules and Regulations Bylaws" and staff interview, it was determined that the facility failed to ensure that the medical screening exam (MSE) was conducted by individuals who are determined qualified by hospital bylaws or rules and regulations.

Findings include:

1. On 7/28/17 review of the facility document titled, "Medical Staff Code of Conduct Rules and Regulations Bylaws" lacked evidence of a definition of a QMP (qualified medical personnel).

2. Upon interview on 7/28/17, Staff #4 stated that the QMP would be a person that goes thru the credentialing process.

3. The facility failed ensure that the MSE was conducted by individuals who are determined qualified by hospital bylaws or rules and regulations.

4. The above findings were confirmed with Staff #4.




B. Based on medical record review, review of facility documents, and staff interview, it was determined that the facility failed to ensure patient's MSE are prioritized appropriately.

Findings include:

1. Review of Medical Record #19, at the Washington Township Division on 7/24/17, revealed the following:

a. According to the patient's face sheet, the patient was admitted on [DATE] at 07:51.

b. The Patient's quick registration was completed on 7/16/17 at 15:24.

c. The "Daily Log in Labor and Delivery" states, the patient's "Time in" was 15:50. The MSE was completed at 16:17.

2. Upon interview, Staff #22 stated that sometimes L&D (Labor and Delivery) patients go directly to the unit. The time on the face sheet is the time that the full registration is completed.

a. The full registration was completed on 7/18/17 at 07:51.

b. The admission time on 7/16/17 was therefore reflective of the time that the patient was fully registered on 7/18/17.

3. Review of Medical Record #20, at the Washington Township Division on 7/24/17, revealed the following:

a. According to the patient's face sheet, the patient was admitted on [DATE] at 09:40.

b. The Patient's quick registration was completed on 7/3/17 at 16:45.

c. The "Daily Log in Labor and Delivery" states, the patient's "Time in" was 16:50 PM. The MSE was completed at 18:11.

4. Upon interview, Staff #22 stated the time on the face sheet is the time that the full registration was completed.

a. The full registration was completed on 7/5/17 at 09:40.

b. The admission time on 7/3/17 was the time the patient was fully registered on 7/5/17.

5. The facility failed to ensure that an accurate admission time was on the patient's face sheet. Due to the inaccurate admission time, the facility was unable to determine if the MSE was prioritized appropriately under the EMTALA law.

6. The above findings were confirmed with Staff #1 and Staff #22.




C. Based on document review and staff interview it was determined that the facility failed to ensure all patients presenting to the ED are provided with a medical screening exam.

Findings include:

Reference #1: Facility policy, Emergency Care Compliance, states, "... Once EMTALA is triggered, the Hospitals must not delay in providing a medical screening examination ..."

1. Documentation in Medical Record #4 revealed the following:

a. The patient (MDS) dated [DATE] at 15:45 with a complaint of lower abdominal and back pain.

b. The patient was triaged at 16:09, classified as ESI 3, and moved to the ED lobby.

c. The patient left the ED on 7/19/2017 at 21:20, five hours and thirty-five minutes after arrival.

d. There was no documentation of a MSE being completed by a QMP, for this patient.

2. Documentation in Medical Record #6 revealed the following:

a. The patient (MDS) dated [DATE] at 13:09 with a complaint of vomiting and weakness.

b. The patient was triaged at 13:27, classified as ESI 3, and moved to the ED lobby.

c. The patient left the ED on 6/22/2017 at 18:18, five hours and nine minutes after arrival.

d. There was no documentation of a MSE being completed by a QMP, for this patient.

3. Documentation in Medical Record #7 revealed the following:

a. The patient (MDS) dated [DATE] at 15:06 with a complaint of right lower extremity numbness and pain from the hip to the foot.

b. The patient was triaged at 15:17, classified as ESI 3, and moved to the ED lobby.

c. At 19:24, the patient was moved from the ED lobby to Sub-Acute Hall #19.

d. At 19:31, the patient was moved from Sub-Acute Hall #19 to the ED lobby.

e. At 19:20, the Nurse Note states, "Called multiple times all areas checked no answer LWT (left without treatment)."

f. The patient disposition states, "Left Without Treatment/LWT" on 6/22/2017 at 19:33.

g. The patient left the ED on 6/22/2017 at 19:33, four hours and twenty-seven minutes after arrival.

h. There was no documentation of a MSE being completed by QMP, for this patient.

4. Documentation in Medical Record #22 revealed the following:

a. The patient (MDS) dated [DATE] at 18:26 with a complaint of abdominal pain.

b. The patient was triaged at 18:51, classified as ESI 3, and moved to the ED lobby.

c. At 23:09, the patient was moved from the ED lobby to ED #11.

d. At 23:20, the patient was moved from ED #11 to the lobby.

e. A 22:50, the Nurses Note states, "Attempted to call patient back to be seen but unable to find patient."

f. The patient disposition states, "Left Without Treatment/LWT" on 1/6/2017 at 23:24.

g. The patient left the ED on 1/6/2017 at 23:24, four hours and fifty-eight minutes after arrival.

h. There was no documentation of a MSE being completed by a QMP, for this patient.

5. Documentation in Medical Record #23 revealed the following:

a. The patient (MDS) dated [DATE] at 16:22 with a complaint of abdominal pain.

b. The patient was triaged at 17:45, classified as ESI 3, and moved to the ED lobby.

c. The Triage assessment at 21:04 states, "Patient called x (times) 2, no answer in waiting room." The total time from arrival in ED to being called was four hours and forty-two minutes.

d. The documented assessment in "Triage" of the ED record at 22:50 states, "Patient called for a third time, no answer in waiting room. Patient name will be taken off board."

e. The documented disposition of the patient in the ED record was "Left Without Treatment/LWT" on 1/6/2017 at 22:50.

f. The patient left the ED at 22:50, six hours and twenty-eight minutes after arrival.

g. There was no documentation of a MSE having been completed by a QMP, for this patient.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on medical record review, review of facility policies and procedures, review of facility documents, and staff interview, it was determined that the facility failed to provide evidence of reassessments for patients classified with an ESI level three (3) according to facility policy.

Findings include:

Reference #1: Facility policy, Assessment/Reassessment (Procedure Steps), states, " ... 6. Reassess the patient as directed by acuity level and/or by the patient condition ... b. Level 3 - every two hours ..."

Reference #2: Facility policy, Nursing Documentation for Low Acuity Patients, states, "A full set of vital signs will be taken during initial assessment. Vital signs will be repeated if: a) Patient remains in ED for over 2 hours b) Initial vital signs were outside normal limits, focused at minimum on abnormal parameter."

1. Medical record review, conducted at the Washington Division on 7/24/17, revealed the following:

a. Medical Record #1, indicated that the patient (MDS) dated [DATE] at 14:44 with complaints of right leg numbness and tingling and upper extremity weakness.

i. The patient was triaged at 14:52, classified as ESI 3, and moved to the Lobby.

ii. The patient was reassessed at 14:49, 16:45, 20:03, and 22:24.

iii. There is no evidence that the patient was reassessed at 18:45.

iv. At 20:03, a Nursing Procedure Communications note states, "Stroke Alert Called."

b. Medical Record #4, indicated that the patient (MDS) dated [DATE] at 15:45 with complaints of lower abdominal/back pain.

i. The patient was triaged at 16:09, classified as ESI 3, and moved to the lobby.

ii. There is no evidence that the patient was reassessed at 18:09 and 20:09.

iii. At 21:20, the Nurse's Note states, "pt (patient) called 3 x by this RN (Registered Nurse) with no answer."

iv. The patient disposition was "Left Without Treatment."

c. Medical Record #6, indicated the patient (MDS) dated [DATE] at 13:09 with complaints of vomiting and weakness.

i. The patient was triaged at 13:27, classified as ESI 3, and moved to the lobby.

ii. The patient was reassessed at 13:24 and 17:13.

iii. There is no evidence that the patient was reassessed at 15:24.

iv. At 18:18, the patient disposition was "Left Without Treatment."

d. Medical Record #7 indicated the patient (MDS) dated [DATE] at 15:06 with complaints of RLE (right lower extremity) numbness and pain from hip to foot.

i. The patient was triaged at 15:17, classified as ESI 3, and moved to the lobby.

ii. The patient was reassessed at 15:10.

iii. There is no evidence that the patient was reassessed at 17:10 and 19:10.

iii. At 19:20, the Nurse's Note states, "called multiple times all areas checked no answer LWT."

e. Medical Record #14 indicated the patient (MDS) dated [DATE] at 11:21 with complaints of left flank pain.

i. The patient was triaged at 11:42, classified as ESI 3, and moved to the lobby.

ii. There is no evidence that the patient was reassessed at 13:42.

iii. At 15:24, the Nurse's Note states, "no answer x 2."

iv. At 16:01, the Nurse's Note states, "no answer x 3."

v. At 16:02, the patient's disposition states, "Left Without Treatment".

f. Medical Record #18 indicated the patient (MDS) dated [DATE] at 14:49 with complaints of upper abdominal pain for 2-3 weeks.

i. The patient was triaged at 14:56, classified as ESI 3, and moved to the lobby.

ii. There is no evidence that the patient was reassessed at 16:56.

iii. At 18:37, the Nurse's Note states, "unable to locate patient to take to treatment area."

iv. At 18:59, the Nurse's Note states, "Pt. called in lobby, no answer @ 18:58."

v. At 19:00, disposition documented as "Left Without Treatment."

2. The above findings were confirmed with Staff #1 and Staff #2.

3. Medical Record review, conducted at the Stratford Division on 7/26/17, revealed the following:

a. Medical Record #21 indicated the patient (MDS) dated [DATE] at 13:54 with complaints of vomiting and shortness of breath.

i. The patient was triaged at 14:22, classified as ESI 3, and moved to the lobby.

ii. The patient was not reassessed at 16:22.

iii. At 17:00, the Nurse's Note states, "not in WR (waiting room)."

iv. At 18:35, the patient's disposition was documented as "Left Without Treatment."

b. Medical Record #22 indicated the patient (MDS) dated [DATE] at 18:26 with complaints of abdominal pain.

i. The patient was triaged at 18:51, classified as ESI 3, and moved to the lobby.

ii. There is no evidence that the patient was reassessed at 20:51 and 22:51.

iii. At 23:24, the patient's disposition was documented as "Left without Treatment."

c. Medical Record #23 indicated the patient (MDS) dated [DATE] at 16:22 with complaints of abdominal pain.

i. The patient was triaged at 17:45, classified as ESI 3, and moved to the lobby.

ii. There is no evidence that the patient was reassessed at 19:45.

iii. At 21:04, Triage Assessment documentation states "Patient called x 2, no answer in waiting room."

iv. At 22:50, a third attempt was made to locate the patient; the patient's disposition was documented as "Left Without Treatment."

4. The above findings were confirmed with Staff #13 and Staff #23.

5. Medical record review conducted at the Cherry Hill Division on 7/28/17, revealed the following:

a. Medical Record #35 indicated the patient (MDS) dated [DATE] at 21:15 with complaints of muscles spasms in back/left flank pain.

i. The patient was triaged at 21:53, classified as ESI 3, and moved to the lobby.

ii. The patient was reassessed at 02:28.

iii. There is no evidence that the patient was reassessed 23:53 and 1:53.

iv. At 02:47 on 5/18/17, the patient left Against Medical Advice (AMA).

6. The patients were not reassessed every two hours as indicated in the facility policy.

7. The above findings were confirmed with Staff #13 and Staff #40.

B. Based on medical record review, review of facility policies and procedures, and staff interview, it was determined that the facility failed to ensure all patients receive appropriate assessment, management, and treatment of pain.

Findings include:

Reference #1: Facility policy, Pain Management, states, "Pain Assessment ... 4. If such assessment identifies a positive pain response, the RN will document in the electronic medical record the assigned pain intensity score and conduct a more detailed assessment of the pain characteristics - also known as a comprehensive pain assessment (CPA): a. location ... d. acceptable level of pain (pain goal) ... Key Points ... Lack of pain expression does not necessarily mean the absence of pain... Pain Assessment Tools ... Numerical Scale ... Moderate = 4-6, Severe = 7-10 ... Pain Reassessment: 1. The reassessment of a patient's pain and the effectiveness of the treatment plan should be ongoing. Pain will be reassessed ... no longer than one (1) hour for pharmacological interventions. 2. Document the reassessed pain intensity on the appropriate form within the electronic medical record."

Reference #2: Facility policy, Patient Rights & Responsibilities, states, "... The right to receive pain relief. The right to an appropriate assessment and management of your pain. You have a right to be educated about pain, pain relief measures ..."

1. Medical record review conducted at the Washington Division on 7/24/17 revealed the following:

a. Review of Medical Record #4 revealed the following:

i. The patient (MDS) dated [DATE] at 15:45 with complaints of lower abdominal/back pain.

ii. At 16:06, the patient reported a pain level of nine (9) out of ten (10) on the facility's numeric scale.

iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal).

iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain.

iv. There is no evidence that the patient's pain was reassessed per facility policy.

b. Review of Medical Record #6 revealed the following:

i. The patient (MDS) dated [DATE] at 13:09 with complaints of vomiting/weakness.

ii. At 13:24, the patient reported a pain level of five (5) out of ten (10) on the facility's numeric scale.

iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal).

iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain.

v. There is no evidence that the patient's pain was reassessed as indicated in the facility policy.

c. Review of Medical Record #7 revealed the following:

i. The patient (MDS) dated [DATE] at 15:06 with complaints of RLE (right lower extremity) numbness and pain from hip to foot.

ii. At 15:10, the patient reported a pain level of eight (8) out of ten (10) on the facility's numeric scale.

iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal).

iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain.

v. There is no evidence that the patient's pain was reassessed as indicated in the facility policy.

d. Review of Medical Record #11 revealed the following:

i. The patient (MDS) dated [DATE] at 21:23 with complaints of suicidal ideation, crisis evaluation, and 8/10 generalized pain.

ii. At 21:30, the patient reported a pain level of eight (8) out of ten (10) on the facility's numeric scale.

iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal).

iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain.

e. Review of Medical Record #14 revealed the following:

i. The patient (MDS) dated [DATE] at 11:21 with complaints of left flank pain for 3 days.

ii. At 11:38, the patient reported a pain level of ten (10) out of ten (10) on the facility's numeric scale.

iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal).

iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain.

v. There is no evidence that the patient's pain was reassessed as indicated in the facility policy.

f. Review of Medical Record #18 revealed the following:

i. The patient (MDS) dated [DATE] at 14:49 with complaints of upper abdominal pain for 2-3 weeks.

ii. At 14:53, the Emergency Flow Sheet Record revealed that the "Pain" section was blank.

iii. There was no evidence that a comprehensive pain assessment was performed.

2. The above findings were confirmed with Staff #1, Staff #2, Staff #4 and Staff #6.

3. Medical record review, conducted at the Stratford Division on 7/26/17, revealed the following:

a. Review of Medical Record #22 revealed the following:

i. The patient (MDS) dated [DATE] at 18:26 with complaints of abdominal pain.

ii. At 18:46, the patient reported a pain level of eight (8) out of ten (10) on the facility's numeric scale.

iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal).

iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain.

v. There is no evidence that the patient's pain was reassessed as indicated in the facility policy.

b. Review of Medical Record #23 revealed the following:

i. The patient (MDS) dated [DATE] at 16:22 PM with complaints of abdominal pain.

ii. At 17:41, the patient reported a pain level of eight (8) out of ten (10) on the facility's numeric scale.

iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal).

iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain.

v. There is no evidence that the patient's pain was reassessed as indicated in the facility policy.

c. Review of Medical Record #25 revealed the following:

i. The patient (MDS) dated [DATE] at 13:42 with complaints of Psych/Right hand injury.

ii. At 13:49, the patient reported a pain level of six (6) out of ten (10) on the facility's numeric scale.

iii. At 14:31, the patient reported a pain level of seven (7) out of ten (10) on the facility's numeric scale.

iv. At 17:08, Nursing Procedure documentation indicated that splinting was performed for fracture care and pain control.

v. The Medication Administration Summary indicated that Ibuprofen/Motrin was given on 1/6/17 at 16:51, 23:24, and on 1/7/17 at 16:36.

vi. Documentation at 15:30 and 17:30 lacked evidence of a pain assessment.

vii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal).

vii. There is no evidence that the patient's pain was reassessed as indicated in the facility policy.

d. Review of Medical Record #26 revealed the following:

i. The patient (MDS) dated [DATE] at 23:44 with complaints of right arm pain after a fall.

ii. At 23:50, the patient reported a pain level of four (4) out of ten (10) on the facility's numeric scale.

iii. There is no evidence that an acceptable level of pain (pain goal) was established as indicated in the facility policy.

e. Review of Medical Record #30 revealed the following:

i. The patient (MDS) dated [DATE] at 10:36 with complaints of chest pain.

ii. At 10:38, the patient reported a pain level of eight (8) out of ten (10) on the facility's numeric scale.

iii. At 11:10, the patient was given Aspirin 325 mg (milligram) by mouth.

iv. At 11:55, the patient was given Ativan 1 mg intravenously.

v. There is no evidence that the patient's pain was reassessed as indicated in the facility policy.

vi. There is no evidence that an acceptable level of pain (pain goal) was established as indicated in the facility policy.

4. The above findings were confirmed with Staff #13 and Staff #23.

5. Medical Record review, conducted at the Cherry Hill Division on 7/28/17 revealed the following:

a. Review of Medical Record #39 revealed the following:

i. The patient (MDS) dated [DATE] at 20:27 with complaints of abdominal pain.

ii. At 20:34, the patient reported a pain level of ten (10) out of ten (10) on the facility's numeric scale.

iii. At 21:00, Morphine 4 mg intravenous (IV) was ordered for the patient.

iv. At 21:10, pain reassessment revealed pain level of six (6) out of ten (10), pain medication was held, reason stating "Pain controlled at present ..."

v. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal).

vi. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain.

6. The above findings were confirmed with Staff #13 and Staff #40.




C. Based on medical record review, review of facility policy and procedure, and staff interview, 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.

Findings include:

Reference #1: Facility policy, Leaving the Emergency Department Without Treatment, states, "...Procedure: ...Risks associated with leaving before evaluation and treatment will be reviewed with patient. Triage nurse/designee will document discussion of risks. Patient will be asked to sign a left without treatment form (located in the electronic record). If patient choose not to sign, triage nurse/designee will document refusal. If patient is called in the lobby and cannot be found, two additional attempts will be made to locate the patient before the patient is designated without treatment. The triage nurse/designee will document each attempt to locate patient ..."

1. Medical record review revealed that six (6) out of 6 medical records (#4, #6, #7, #21, #22, #23) of patients that left the facility without treatment did not contain a signed "Left Without Treatment" form.

2. Medical record review revealed that five (5) out of six (6) medical records (#4, #6, #7, #22, #23) of patients that left the facility without treatment did not contain written documentation of refusal to sign.

3. Medical record review revealed that five (5) out of six (6) medical records (#4, #6, #7, #22, #23) of patients that left the facility without treatment did not contain written documentation of three individual attempts to locate the patient before the patient was designated as left without treatment.

4. The above findings were confirmed with Staff #4, Staff #6, Staff #13, Staff #23, and Staff #40.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
Based on medical record review, review of facility policy and procedure, and staff interview, it was determined that the facility failed to provide an appropriate patient transfer.

Findings include:

Reference: Facility policy, Transfer of Patients, states, "... The patient is informed of his/her rights (Emergency Medical Treatment and Active Labor Act 1986). ...Purpose To ensure the appropriate transfer of a patient from one facility to another. Steps The ED Physician Will: ...2. Explain risks and benefits of transfer to the patient and/or family 2. Key Points 2. Informed consent should be documented. Risks discussed should include accident during transport and complications occurring during transport. The Physician Will ...3. Complete authorization for transfer consent form and have patient or family member sign. ...The ED Nurse or designee will: ...8. Contact the receiving nurse including: -time of departure -equipment to be returned -personnel accompanying patient -mode of transport and ETA -patients current condition Key Points Document all information in EDIS. ..."

1. Medical records reviewed at the Washington Township Division on 7/24/17, revealed the following:

a. Medical Record #11 had an "Authorization for Transfer" form that failed to include the patients signed consent to transfer.

b. Medical Record #12 had an "Authorization for Transfer" form, completed by the physician, that failed to include the date and time.

i. There was no evidence that the ED Nurse or designee contacted the receiving facility nurse regarding Patient #12's transfer.

2. The above findings were confirmed with Staff #6.

3. Medical records reviewed at the Stratford Division, revealed the following:

a. Medical Record #25 had an "Authorization for Transfer" form that failed to include the patients signed consent to transfer.

i. Medical Record #25 lacked evidence that a verbal report was given to the receiving facility nurse.

ii. The above findings were confirmed with Staff #23.

b. Medical Record #28 had an "Authorization for Transfer" form that failed to include physician's signature.

4. The above finding was confirmed with Staff #4 and Staff #13.