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.

Based on observation and review of posted signs and interview, it was evident that the emergency department posted a sign that had the potential for discouraging persons with no official identification from accessing emergency services.

Findings include:

During the tour of the ED on 5/16//11 at approximately 3 PM, a posted sign was observed in both the pediatric and adult waiting rooms of the ED. The signs contained the following language:

" Please note valid photo identification is required at each visit to the Emergency department . Acceptable proofs are New York State photo identification and valid driver license."

The sign represents a strong potential for discouraging undocumented persons, persons who have no drivers licenses, and those with other potential legal or economic issues from accessing care as patients in the emergency room .

At interview with the administrative ED staff on 5/16/11 it was stated that the signs should be removed and that all persons are seen for care regardless of the ability to show proof of identity. The staff attested that no patient presenting to the ED is denied care.

Based on review of records and documents as well as staff interview, it was determined the hospital did not provide timely triage or complete assessment of symptoms for a patient brought to the hospital by ambulance following a motor vehicle accident.

Findings include:

Review of medical record #1 on 5/16/11 found there was a delay in triage assessment for this patient who arrived to the hospital by ambulance on 3/5/11 following a motor vehicle accident.

Review of MR #1 found there was inconsistent documentation for time of arrival and an incomplete triage assessment.

Review of the medical record , the ED log, and the ACR finds that there is documented evidence that the patient arrived at the hospital destination on 0629 AM on 3/5/11 and was triaged at 0654 AM, constituting a delay of 25 minutes.

Specifically, the medical record triage notes and ED log notes the patient's time of arrival as 6:52 AM, which is at variance with the time noted for of arrival on the ambulance all report (ACR), which reports instead the patient arrived to the hospital destination at 0629 AM.
However it was also determined from medical record review that the first EKG was performed at 6:42 AM, which is prior the hospital's stated time of ED arrival and triage.
The triage assessment note documented, "MVC passenger -c/o right side pain". This triage note was incomplete in that it referred to the side of the pain but not the site of the pain.
Furthermore, it was also determined that although EMS documented an allergy to penicillin the triage assessment in the medical record indicated no known allergies.

In addition, the review of the documented medical assessment dated [DATE] at 9:15 AM found it was incomplete.

While there was evidence from complaint investigation documents that the patient made a complaint of a headache in the course of treatment at the hospital, there was no documented evidence in the notes that the medical staff assessed the source of the complaint of the headache during the course of her emergency care.
Review of this follow-up complaint investigation documents on 5/16/11 found that the patient made a complaint of a headache in the course of treatment at the hospital , but there was no documented evidence in the medical record the alleged headache was addressed. While the record noted no evidence of head trauma, it lacked an assessment by the medical staff of the complaint of the headache during the course of her emergency care. In addition, the medical screen lacked documentation of the assessment of the patient's refusal for immobilization by emergency medical ambulance personnel.

There is no reference to the patient having a headache in the medical record or requesting a MRI of the head. However, there was documented evidence in written statements made by the MD and investigative notes from the hospital that the patient requested such a test and it was declined by the medical staff. The patient's request for CT/MR of brain for " headache " was not referenced in any note in the medical record, to explain why this test was deferred even if not clinically indicated.

It was determined through interviews with the facility's administrative staff on 5/16/11 that the record did not note any reference nor investigation regarding the complaint of headache and deferral of the MRI by the MD.