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MONTEFIORE MOUNT VERNON HOSPITAL 12 NORTH 7TH AVENUE MOUNT VERNON, NY 10550 Jan. 13, 2015
VIOLATION: DELAY IN EXAMINATION OR TREATMENT Tag No: A2408
Based on medical record reviews, staff interviews and policy reviews, it was determined patients did not receive appropriate and timely care based on the type of insurance. This was found in 2 of 29 medical records reviewed. This was found in medical records (patient) #1 and #3.

Findings include:

1. There was a delay in providing care to patients who had Affinity Insurance that presented to the Montefiore Mount Vernon Emergency Department (ED).

A review of medical record #3 on January 12, 2015 revealed this patient presented on December 18, 2014 at 5:13 AM "yelling and screaming." An ecchymotic area (skin discoloration caused by the seepage of blood into the tissues from rupture blood vessels) was noted on the patient's left outer thigh. The nursing staff noted that the patient had observable signs of mental illness, was feeling anxious, was agitated and that she had dramatic mood changes. The physician documented that the patient was agitated, crying and and that she had a psychotic behavior. There was no documentation that the staff attempted to ascertain the nature of the patient's ecchymotic thigh.

A review of the medical record on January 12, 2015 revealed upon arrival the patient was yelling, not following any oral commands, but was "stating mommy tell dad not to do this, he is hurting me." Then the patient removed all her clothing and eloped. The record does not indicate when the patient eloped and when she returned even though she was placed on constant observations upon arrival. The patient's global assessment of functioning (GAF) was 20 [a score within the 11 to 20 range indicates some danger of hurting self or others, or occasionally fails to maintain minimal personal hygiene, or gross impairment in communication // the GAF numeric scale is: 0 inadequate information, 1 to 10 persistent danger of severely hurting self or others, or persistent inability to maintain personal hygiene, up to 91 to 100 no symptoms - superior functioning in a wide range of activities] and she had a previous medical history of Post Traumatic Stress Disorder (PTSD), Psychotic episodes and Cannabis abuse.

Further review of the medical record on January 12, 2015 revealed the psychiatric consultation done at 10:31 AM indicated "due to repeated ED visits with unclear interim outpatient treatment of underlying illness, recommend consider an inpatient mental health admission. Patient has Affinity Insurance and cannot be admitted for inpatient mental health to Montefiore Mount Vernon." The patient was later evaluated by the chairman of Psychiatry who approved the patient's discharge from the ED that day at 12:35 PM.


2. A review of medical record #1 on January 12, 2015 revealed this is a twenty-seven year old patient who presented on January 4, 2015 at 11:01 PM with a complaint of hearing voices, poor sleep and depressed appetite for the past 2 days. The patient was worried about her 4 year old daughter who was in the custody of her (daughter's) father. The psychiatrist did not explore the nature of the patient's hallucinations. The patient was discharged from the ED on January 5, 2015 at 12:32 AM. The patient went to a police station and told them she was hearing voices and seeing things. The patient was taken back to the facility that day (January 5, 2015) at 9:12 AM. The triage nurse noted that the patient was not answering questions and that she had observable signs of depression. The patient was combative at times and her global assessment of functioning (GAF) was 15. The patient was thought blocking and her insight and impulse control were poor. A decision was made to admit the patient.

Further review of the medical record on January 12, 2015 revealed the patient remained in the ED until January 7, 2015 while awaiting a bed at another facility because her insurance was not in network. Documentation that morning at 11:10 AM revealed the patient's hallucinations had subsided, however, the patient was discharged at 1:10 PM that day.

The Chairman of Psychiatry was interviewed on January 13, 2015 at 2:00 PM at which point he stated that patients that have Affinity Insurance are out of network and therefore they cannot be admitted here.

The patients did not receive necessary care because the patients health insurance was not part of the facility's insurance network.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on medical record reviews and staff interviews, it was determined a patient did not receive an appropriate medical screening examination when he presented to the emergency department (ED). This was found in 1 of 29 medical records reviewed for patient #2.

Findings include:

This patient did not receive an appropriate medical screening examination prior to his discharge from the ED.

A review of patient #2's medical record (MR #2) on January 12, 2015 revealed the patient, who is a welder, presented to the ED at 7:07 AM on Friday, September 26, 2014 with a complaint of eye trauma that had occurred the previous day. The patient's pain level was 9 on a scale of 0 (no pain) to 10 (worst pain imaginable). A telephone eye consultation was done and the patient was discharged from the ED at 8:12 AM that morning for an eye consultation at another location. The record notes the patient was discharged to go to the doctor's office at 202 Steven's Avenue in Mount Vernon. The patient returned to the ED at 9:56 AM that morning where it was noted that the patient had a dislocated lens in the left eye.

The patient was transferred to another location where another eye consultation was conducted at 4:00 PM that day. This consultant noted the patient had a displaced lens with vitreous humor coming forward into the anterior chamber and that there was a peripherally shallow anterior chamber with elevated intraocular pressure. Treatment recommendation was to insert Pred Forte 1 drop every 2 hours, Cosopt bis in die (BID = Latin for "twice daily") and Atropine BID. The patient was to follow-up with doctor the following day and Monday.

These findings were discussed with the Director of Quality Management on January 12, 2015 at approximately 2:00 PM.

The patient's discharge from the hospital at 8:12 AM on September 26, 2014 for an eye consultation at another location was inappropriate given the nature and location of the patient's trauma.