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RICHMOND UNIVERSITY MEDICAL CENTER 355 BARD AVENUE STATEN ISLAND, NY 10304 March 28, 2014
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interviews, the review of medical and other documents, it was determined that the facility failed to integrate the hospital's emergency department with outpatient services to assure continued care of Emergency Department (ED) patients post discharge. Specifically, written follow-up plan, for discharge patients with no identified Primary Care Provider, failed to include referrals for follow up care. This finding was noted in 3 of 10 applicable records reviewed (Patient Records #1, 2, and 3).

Findings include:

Record review documents Patient #1 is a [AGE] year-old female who was triaged in the Emergency Department on 03/18/14 at 2:03 PM for complaint of vaginal bleed and lower abdominal pain. The patient stated she was two months pregnant. The patient's past medical history was significant for Asthma, psychiatric disorder and polysubstance abuse. The triage classification was Emergency Severity Index: Level 3.

A trans-vaginal sonogram revealed incomplete spontaneous abortion in progress.

Following review of laboratory tests and sonogram report, the ED physician notes her clinical impression was "Threatened Abortion". The physician indicated the patient does not have a condition that requires further testing in the Emergency Department.

The physician notes that the patient received a verbal and a written instruction regarding her condition and that "follow up is to be arranged by caretaker with OB/GYN (obstetrics/gynecology) doctor in 2 days".

The patient returned to the ED on 03/18/14 at 7:45 PM and states she "NEED MORE INFORMATION". The patient was again evaluated by the ED physician and discharged at 8:46 PM with instructions to make an appointment with her gynecologist in 1-2 days.

Although the triage assessment conducted on 03/18/14 at 2:03 PM and again on 03/18/14 at 7:45 PM documented the patient had no Primary Medical Doctor/Primary Care Practitioner (PMD/PCP), the discharge instruction for the two ED visits on 03/18/14 notes a follow- up with the patient's Obstetrician in 2 days for further evaluation.

The facility's Emergency Department policy titled "Discharge of the patient" last reviewed in March 2014 notes that "all patients discharged from the Emergency Department will have an appropriate follow-up plan developed before discharge by the licensed health care providers involved in their treatment. The patient is provided with aftercare instructions and a plan for follow-up care to ensure continuing care after discharge".

The information provided, that the patient did not have a PMD/PCP, was not utilized by the licensed care providers in the development and implementation of a plan for her continued care after discharge. The patient's record and discharge instruction did not contain referrals for appropriate follow-up care in 2 days as directed by the ED physician.

During interview with the Staff #1 on 03/27/14 at 2:45 PM, he stated the patient was given additional information to make a follow up appointment. The staff however acknowledged that the information was not included in the written or verbal instruction documented by the ED physician responsible for patient's discharge and follow up plan.

Record review documents Patient #2 is a [AGE] year-old male with no significant medical history who (MDS) dated [DATE] and triaged at 11:19 PM for complaint "something in the eye".

The patient later reported to the physician during evaluation that he was cutting steel at work on 03/07/14 when something entered his left eye and now has worsening pain.

The triage assessment on 03/08/14 at 11:19 PM documents that the patient had no "PMD/PCP".

Physician examination documented 20/20 visual acuity in left and right eye; mild redness of conjunctivae; embedded foreign body to medial aspect of corneal and below pupil of left eye; fluorescein eye stain was positive for corneal uptake which is an indication of corneal abrasion.

The procedure note indicated the foreign body was removed. The physician's (Staff #2) clinical impression was "corneal foreign body with removal". The physician notes the patient received written and verbal instructions regarding his condition and follow-up care is to be arranged by patient with ophthalmology in 1 day. The patient was discharged on [DATE] at 1:02 AM.

During interview with Staff #2 on 03/28/14 at 10:15 AM, she stated an embedded foreign body on the patient's left cornea was removed during the ED visit on 03/08/14 but that Staff #2 was aware that all the foreign body was not removed prior to the discharge of the patient on Sunday, 03/09/14. Staff #2 stated the patient was instructed to follow-up with an ophthalmologist the next day on 03/10/14. She added that the patient was given the option to either follow-up with his ophthalmologist or at the hospital's ophthalmology clinic on 3/10/14.

During interview with Staff #1 on 03/28/14 at 11:40 AM, he stated the patient's condition was deemed stable for discharge and was referred for follow-up care. Staff #2 stated the patient had no visual changes or penetrating injury that would have required immediate ophthalmology consultation and treatment.

The facility's Emergency Department policy titled "Discharge of Patient" was not implemented. The discharge plan provided instruction for follow up care with an ophthalmologist on 03/10/14, but the plan did not ensure that an appointment was secured for the patient who required a next day appointment to ensure prompt evaluation and removal of foreign body in his left eye.

The patient returned to the Emergency Department the next day on 03/10/14 at 13:34 (1:34 PM) with complaint of "steel in the eye" and severe pain rated 9/10 on a pain scale of 1-10. The patient was evaluated by the physician with the impression of "foreign body in left eye and corneal abrasion".

The patient was not seen by the ophthalmologist until 03/11/14.

At interview with patient's mother on 04/03/14 at 11:30 AM, she stated her son was discharged from the ED in the early morning on Sunday (03/09/14) and instructed to follow-up with his ophthalmologist or at the hospital clinic the next day. She stated her son returned to the ED on 03/10/14 for further evaluation of severe pain in his left eye as he could not obtain an ophthalmology appointment for Monday 03/10/14.

Record review documents Patient #3 is a [AGE]-year-old female who was evaluated in the Emergency Department on 03/27/14 for swelling to her right arm. On 03/27/14 at 3:56 PM, the physician notes that after evaluation of the patient the clinical impression is arthritis, right hand.

The triage assessment notes indicated the patient answered "doesn't know" when she was asked to provide information regarding her PMD/PCP.

The written discharge information, "Aftercare Instructions" provided to the patient indicated the patient is to arrange follow-up with rheumatology/PMD in 2 days. The discharge instruction did not include referral for follow-up care with rheumatology/PMD as indicated in the follow up plan developed by the ED physician.

At interview with Staff #1 on 03/28/14 at 11:30 AM, he stated patients are instructed to follow-up in outpatient clinics, but acknowledged that the written discharge instruction lacked specific information on where the patient would receive follow-up care.