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MOUNT SINAI BETH ISRAEL FIRST AVENUE AT 16TH STREET NEW YORK, NY 10003 Sept. 10, 2013
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on record review, review of documents, policy, and interviews it was evident that the Emergency Department (ED) staff failed to provide a patient with a medical screening examination (MSE). Additionally, the hospital failed to implement and have a complete policy for the discharge of patients from the ED. This finding was identified in one of one applicable records reviewed. (MR#1)

Findings include:
Review of the ED medical record #1 on 9/5/13 at approximately 10 AM found that the patient walked in and presented to the triage area of the adult ED on 8/7/13 at 11:07 AM with the complaint of asthma with intermittent wheezing and chest tightness for 4 days. The patient was assigned the triage category of ESI (emergency severity index ) of 3 which is interpreted as " urgent" on the ED record. The vital signs were within normal limits (blood pressure (B/P)114/73, pulse 62, respiration 22 ) . The pulse oximetry (a measure of oxygen saturation, or how much oxygen the blood carries) was noted as 100% on room air . Under the section in the Emergency triage record for " complaint " it was entered as "asthma." . There was no past medical history noted in the record. There was a reference in the record that the pain severity index for the numerical standard of 1 to 10 with 10 being the highest was reported by the patient to be 7 out of 10. No location of the pain was noted. At 11:10 AM the record stated that the patient was assigned a "charge physician ".

Review of the Security Incident Department report on 9/9/13 referenced the patient in MR #1 and was dated 8/7/13 at 11:30 AM. This report, which was prepared by the responding Sergeant had noted " disruptive " under the section labeled "title of incident". Under the section for description of incident it was noted that " the Sergeant responded to the ED orange pod asthma area to assist another officer who had responded to the area because of complaints that a patient (MR#1 ) was using his cell phone to record staff in the ED and refused to stop." " The patient's demeanor became threatening when he was apprehended and asked to stop. " There is no reference in this incident report that the patient was recording " patients. "

It was recorded in the Security incident report dated 8/7/13 at 11:30 AM that the nurse manager requested that security escort the patient out of the ED which was done " without incident. " It was further noted by the security Sergeant that after NYPD officers responded to the ED they informed the ED staff that they could not confiscate the patient's cell phone.

The re-assessment note entered by the attending physician on 8/7/13 at 11:48 AM documented "Patient was videotaping patients and staff in the ED by security , NYPD called for trespass."

Further review of the ED record on 9/5/13 found that on 8/7/13 at 11:48 AM the nursing notes written by the Assistant Nurse Manager documented " Patient was escorted out of ED by security. Medically cleared by the attending. Patient was videotaping the ED pod. (Pod references a section of the ED where treatment is provided). Was asked to put his phone away. Patient refused. Continued videotaping in the ED. Patient became physical with security. NYPD (New York Police Department) called. Patient outside ED. "

On the face sheet of the ED record for MR#1, under the section titled " Patient Disposition " , it was noted: 11- Walk out not seen - 8/7/13 12:59 PM and the name of the attending who stated that he " medically cleared the patient for discharge " earlier in the record.

Under the section of the ED record titled , "discharge condition" dated 8/7/13 timed at 1:13 PM it was noted by the staff nurse " Note: patient escorted out of ED by security earlier. Condition - stable."

At 1:15 PM on 8/7/13 there is another nursing note written by a staff nurse from the ED that recorded " pain severity score at discharge -none noted - pain not assessed. "

At interview with the Assistant Nurse Manager on 9/6/13 at approximately 11:00 AM, it was stated that she observed the patient videotaping and behaving in a disruptive manner in the orange pod of the ED which has an area designated as the asthma treatment area.

At interview with the attending physician referenced above on 9/9/13 at 1:00 PM who wrote the re-assessment note on 8/7/13 at 11:48 AM it was stated that he did not conduct any examination of the patient and that he called 911 and hospital security at about 11:30 AM after he was advised by nursing staff that the patient in MR#1 was videotaping staff and patients in the ED and was raising his voice. The patient refused to cease recording and surrender his phone. The physician stated that he medically cleared the patient for discharge or arrest. He stated that he never "auscultated" (listening to breath sounds using a stethoscope) the patients lungs, performed any peak flow or conducted a medical history in the usual manner. He stated that he acted in reliance of the normal vital signs recorded by triage 30 minutes prior and that any patient who can raise his voice that loudly cannot be having any serious respiratory symptoms. He further stated that he prepared a document that advised the patient that if he returned to the ED that he would be arrested for trespass. He stated that he was advised to write such a notice by the NYPD officers to ensure that the patient was warned that if he returned he would subject to arrest for trespass. He stated that he " lost " a copy of that document. The physician also acknowledged that he did not document the provision of this notice to the patient in the medical record.

At interview with the Deputy Chief of Emergency Medicine on 9/9/13 at 11:00 AM it was stated by him that he aware that there was such a notice given to the patient by the attending physician in the ED.

Review of hospital policy and procedure # 2027F titled " Discharge of Disruptive and / or Non compliant patients " found that under " discharge " security may escort patients off units if the patient is amenable to this. The policy notes that "reasonable efforts must be made to resolve any problem that may be causing or contributing to the disruptive behavior or the refusal to participate in treatment". It further notes that at no time should hospital personnel remove a patient unless that patient is posing an " imminent danger " to others on the unit.

The policy fails to address the need for medical clearance and stability in advance of involuntary discharge. Additionally, there is no documentation in the record or evidence obtained from interviews that the facility complied with its policy. Specifically, there is no documentation of the interventions implemented to try to resolve the problem, provision of alternatives, nor whether the reasons were explored for the disruptive behavior.

At interview with the Security Sergeant on 9/10/11 at 11:00 AM, it was stated that at the nursing manager's request that the patient be removed from the ED and that he and the other officer physically removed the patient out of the ED by placing their hands on the patients arms . He stated that he was advised by the nurse manager that the patient was cleared for discharge.

At interview with the ED Nurse Manager on 9/6/13 at approximately 11:00 AM it was stated that she was not aware of such a policy.