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.

FAXTON-ST LUKE'S HEALTHCARE 1656 CHAMPLIN AVENUE UTICA, NY 13503 Jan. 13, 2015
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on findings from observation, interview and document review, the hospital failed to maintain an accurate central log for patients observed entering the emergency department (ED). Specifically, for 2 out of 2 patients observed entering the ED the Central Log for the ED lacked accurate information regarding the time of presentation to the ED.

Findings include:

-- The hospital policy and procedure (P&P) titled "Emergency Department Patient Registration Process," dated 9/15/14, indicates the ED Liaison "Greets the patient and t-registers the patient into the AS400 system". The P&P lacks direction regarding capturing the real time presentation.

-- Observed Patient S presenting to the ED on 1/8/15 at 1020. The patient was directed by Security Guard #1 to the waiting room. Security Guard #1 wrote down the patient's first name and time he/she presented to the ED.

At 1025 Patient S was called for pre registration.

Patient S's medical record (MR) and the ED Central Log indicated Patient S's arrival time was 1025, not 1020.

-- Observed Patient T presenting to the ED on 1/8/15 at 1020. The patient and his/her parent were waiting for the other parent to interpret. At 1024 the patient and his/her parents were directed by Security Guard #1 to the waiting room. Security Guard #1 wrote down the patient's first name and the time he/she presented to ED as 1024.

At 1030, Patient T and parents were called for pre registration.

Patient T's MR and the ED Central Log indicated Patient T's arrival time was 1030, not 1020.

-- Interview with Security Guard #1 on 1/8/15 at 1035 revealed he/she writes down the time when the patient passes through the locked door, with an identifier, e.g. first name, initials, reason for coming, and directs them to go to the waiting room. The patient is then called by the ED Liason who then pre-registers them. The Security Guard disposes the piece of paper which has the times the patient presents to the ED.

-- Interview with the ED Liason on 1/8/15 at 1040 revealed he/she documents the time of arrival/presentation as the time the pre-registration takes place. The ED Liason does not check with the Security Guard to ascertain the actual time the patient presents. The ED Liason's arrival time is transmitted to the ED Central Log electronically.

-- The above findings were discussed with the Chief Nursing Officer on 1/8/15 at 1045.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on findings from medical record (MR) review, interview, and facility document review, the hospital failed to ensure that a patient who presented to the emergency department (ED) with signs of psychiatric disorder received a medical screening examination (MSE) that included a complete mental health assessment (MHA). Personnel involved in the patient's care did not obtain, document and/or consider all significant clinical information pertinent to the patient's management.

Findings include:

--Review of Patient A's medical record on 1/8/15 revealed the following information:

On 1/6/15 at 1343 information on a form titled "EMS Communication Sheet" indicates emergency medical services (EMS) personnel contacted the ED regarding transport of a male who had been taken into custody by local police department staff (LPD) for a 9.41 Mental Hygiene Law (MHL) emergency admission. (MHL 9.41 indicates peace or police officers may take custody of and transport to a hospital or comprehensive psychiatric emergency program (CPEP) "any person who appears to be mentally ill and is conducting himself or herself in a manner which is likely to result in serious harm to the person or others.") EMS reported the patient was "homicidal uncooperative."

A report titled "PM EMSCHARTS " (a pre-hospital EMS care report), dated 1/6/15 and timed 1423 (faxed time), indicates the patient was MHL status 9.41, impression was behavioral/psychiatric disorder. The report also contains the following statements: " ...pt (patient) admits to using heroin. pt. is combative on attempts to start any ALS (advanced life support) procedure. Per ... (local police department) pt has been abusing animals in his apartment. Pt seems delusional and stated I am the god of war. Pt admits to taking heroin and drinking alcohol. Pt is combative when attempting any assessment. Pt remained in ... handcuffs and put on stretcher through out treatment ... "

A form titled "Law Enforcement Request for Examination" completed by LPD, dated 1/6/15 and signed at 1405, indicates the patient's family reported strange bizarre behavior and animal abuse and that the police officer observed "confused, disoriented threats." Information on the form further describing patient behaviors included the following:

verbal threats and physical gestures of harm to others,
attempted to harm others,
yelling and screaming,
pushing others, incoherent /illogical speech,
talking to self,
failure to respond to questions,
reported hearing voices,
extreme slow speech,
hostile, argumentative belligerent,
overly suspicious/feeling of persecution,
confused/disoriented,
hyperactivity, nodding out,
appears insensitive to pain.

The form indicates there was a potential for violence and restraints/cuffs were being used on the patient.

A form titled "Emergency or CPEP Emergency Admission (Sections 9.41, 9.45, 9.55 and 9.57 Mental Hygiene Law) Custody Transport of a Person Alleged to be Mentally Ill to a Hospital Approved to Receive Emergency or CPEP Emergency Admissions (OMH 474A/476A), completed by a police officer on 1/6/15 at 1404, indicates Patient A was taken into custody by law enforcement for transport to the Faxton-St. Luke's Healthcare ED.

The following information is recorded by nursing staff in the electronic MR (EMR) and by physician staff on a hardcopy form titled "Emergency Provider Record- Psych Disorder, Suicide Attempt, Overdose " :

At 1355, Registered Nurse (RN) #1 triaged the patient as level 2 (on 5 level acuity system, 1 being most acute), documented the chief complaint was "combative psychiatric evaluation," and that "Patient staring into space when EMS called his name and responded who's ... (name)? "He/she also noted the LPD requested 4 point restraints upon arrival, patient was placed in restraints per order of Physician #1 (the attending ED physician), the patient was yelling out, attempting to fight, and security was in the room.

At 1415, Physician #1 saw the patient. His/her documentation included/indicated the following: "EMS arrival 9.41 by local police department with chief complaint of agitation ... the agitation was sudden in onset and mild in severity ... no history from patient at this time." Initially the patient was not able to give any information (was "dazed"). Patient descriptors included in the documentation included hostile, paranoid, anxious, depressed. After discussion with the patient, he did not have suicidal or homicidal ideations. Suicide risk assessment revealed the patient was depressed, had hallucinations, and family was frightened; estimated risk for suicide was low. The patient had a past history of a head injury which involved a foreign body in September, and his social history was positive for drugs (marijuana). Physical examination performed with no remarkable findings.

At 1425, Physician #1 ordered blood and urine laboratory testing that included basic metabolic panel (BMP), complete blood count (CBC), thyroid stimulating hormone (TSH) and urine drug screen, which were obtained. Urine drug screen showed THC (tetrahydrocannabinol/marijuana).

At 1707, Physician #1 ordered "Consult Case Management ED Referral Needs: Discharge Planning." (Per interview with Physician #1 on 1/12/15 at 1130, the electronic component of the MR does not allow order for mental health assessment (MHA) to be entered specifically. When he/she enters an order for a MHA by a social worker in the EMR, he/she clicks on "case management consult for mental health- discharge planning " which means full mental health evaluation by social work and recommendations, e.g., admit, discharge and/or obtain services). There was no documentation entered in the MR by ED Case Management during the time frame Patient A was in the ED.

At 1800 RN #2 documented that restraints were discontinued and Patient A was cooperative with care. Documentation by Physician #1 (not specifically timed) indicated patient improved, restraints removed.

At 1818, RN #3 documented that the patient was alert, oriented and responded to verbal stimuli and cooperative.

At 1830, Physician #1 ordered a CT Scan Head without intravenous (IV) contrast; clinical indication of trauma and confusion, which was obtained at 1855 and showed a 7 mm area of high density in the left cerebellar hemisphere white matter and no evidence for acute intracerebral or extracerebral hemorrhage, mass effect or shift.

Physician #1 checked "Medical clearance for psychiatric referral" on the form and indicated a social worker (Licensed Clinical Social Worker / LCSW #1) would see patient in the ED.

At 1930, Physician #1 indicated he/she had discussion with LCSW #1, mother and patient; patient back to normal; no suicidal ideation, no homicidal ideation.

Physician #1 documented the clinical impression as follows: anxiety, psychosis (resolved) substance abuse and rule-out intracranial bleed. He/she also noted the patient was discharged to home at 1950 (on 1/6/15) in stable condition.

On 1/7/15 at 1132, in a late entry documented in the Discharge Planning Progress Note section of the EMR, LCSW #1 entered "Per doctor request met with pt who was calm and cooperative although a bit paranoid. Asked if I could speak with ... mother and if pt wanted to see her. Pt agreed. Pt's mother reports pt has a history of ADHD (Attention Deficit Hyperactivity Disorder) but had outgrown it. Mother reports no other psychiatric issue ... When mother was asked if she knew of any drug use by pt she responded only marijuana. Pt's UDS (urine drug screen) positive for THC. When mother brought to pt's room pt remained calm and cooperative, appeared to have a positive relationship as she gave him a hug and kiss. Pt denied being homicidal or suicidal and mother agreed that she does not believe pt is a danger to himself or others. Discussed treatment options with pt's mother. Mother thought it would be best for pt to return home, when medically cleared, and access outpatient treatment. Discharge plan discussed with Dr. ... (Physician #1) if pt is not admitted then social work will follow up with outpatient referral during next business day. "

-- The hospital's policy and procedure (P&P) titled "Social Work Services in the emergency room ," developed 4/2014, addresses referrals to Social Work for psychiatric assessments of children and adults. It notes the ED physician will evaluate patient's medical acuity and once determined medically stable, will write order for MHA in the MR for social work referral. It also noted ED physician to refer to psychiatrist if recommended and that the LCSW completes MHA documentation and transfer documentation as appropriate.

--Per interview with LCSW #1 on 1/8/15 at 1350, he/she performs MHAs on patients that are in the ED when the ED physician tells him/her that the patient needs a MHA and/or places an order in the electronic medical record for MHA. After seeing patient for MHA, he/she documents the assessment in the MR and discusses the results with the ED physician, making recommendations regarding the patient. Physician #1 asked him/her to see Patient A. LCSW #1 did not complete a MHA for Patient A on 1/6/15 because the patient had not been medically cleared, a CT Scan Head had been ordered. LCSW #1 thought that Patient A "might be" admitted to the hospital. LCSW #1 was not aware at the time of Patient A's ED presentation that he had been transported to the ED on a 9.41 legal status or that documentation on the 9.41 form indicated report of abuse of animals.

--Per interview with Physician #1 on 1/8/15 at 1530, he/she went in to see Patient A shortly after arrival to the ED and could not get much history as the patient would not comment and looked dazed. After Patient A's mother arrived, the patient improved and Physician #1 was able to talk "quite well" with the patient. Patient A denied suicidal and homicidal ideations. Physician #1's usual process is to try and get an MHA with the ED social worker when a patient comes in as 9.41 status. Physician #1 was not aware that the LCSW in this case had not performed an MHA of Patient A at the time of the ED visit. Regardless, he/she did his/her own MHA of Patient A. There were no red flags. Physician #1 spoke with LCSW #1 who reported the patient was fine, stable with no suicidal or homicidal ideation and mom was okay with taking him home. Physician #1 was aware that Patient A was bought in as 9.41 status but was not aware that documentation on the form indicated there was a report that Patient A had abused animals.

--Per interview with Physician #1 on 1/12/15 at 1130, he/she normally consults the case manager (LCSW) for MHAs and discharge planning. Patients seen in the ED for psychiatric symptoms have medical clearance performed and the social worker does the MHA. Physician #1 stated he/she cannot review the MHA documented by social work in the EMR because it is in another part of the EMR. He/she reads the free text note entered in the EMR by social work instead. During this interview, in contrast to the interview on 1/8/15 at 1530, Physician #1 indicated he/she was aware of 9.41 documentation that Patient A abused animals, but did not know what the abuse entailed.

--Per interview with Physician #2 (another ED attending physician) on 1/12/15 at 1510, MHAs are ordered in the EMR by the ED physician. He demonstrated how to enter an order specifically for a MHA and how to access and view a completed MHA by the social worker in the EMR.

SUMMARY:

- Information on the Law Enforcement Request for Examination form and the EMS care report indicating the patient was reported to have been abusing animals was not incorporated into and/or explored in the nursing, physician or social worker evaluations of the patient. A complete MHA was not performed. As a result, a complete MSE also was not performed.

- Physician #1 was not aware of how to specifically order a MHA by a social worker and thought this was accomplished when he/she selected "Consult case management for mental health- discharge planning" in the orders section of the EMR.

- Physician # 1 was not aware LCSW #1 had not completed a MHA.
VIOLATION: STABILIZING TREATMENT Tag No: A2407
Based on findings from medical record (MR) review and interview, the medical screening examination (MSE) performed for Patient A did not provide assurances his condition was stabilized at the time of discharge. Also, despite request by local law enforcement that it be notified when the patient was discharged , notification did not occur

Findings include:

--Review of Patient A's MR revealed that the MSE performed for this patient who was brought in on a 9.41 Mental Hygiene Law emergency admission status, was not complete. It did not include evaluation of a report the patient was abusing animals pre-admission and did not include a mental health assessment by a Licensed Clinical Social Worker (LCSW), as ordered by the attending ED physician (Physician #1). See details in findings in Tag 2406. As a result, the MSE performed did not provide assurances the patient's condition was stabilized at the time of discharge.

--Also, the form titled "Law Enforcement Request for Examination," completed by the local police department (LPD), dated 1/6/15 and signed at 1405, indicated that if the patient did not require inpatient/psychiatric/medical services, the delivering police agency should be notified prior to release. Phone number of police agency contact is present on the form.

Review of Patient A's MR reveals there is no documentation the LPD was notified of the patient's discharge.

During interview with RN #1 on 1/12/15 at 1315, he/she was not aware that the LPD wanted to be notified when the patient was discharged .