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 document review, videotape review, and staff interview, it was determined the emergency department failed to implement the facility's policy to: (a) offer Emergency medical care for a patient who presented to the facility campus, (b) provide appropriate assessment, treatment, and follow-up care as indicated by the patient's medical condition.

This failure may have placed patients at increased risk for adverse outcomes.

Findings include:

See citations:
Tag A 1103
Tag A 1104

Based on medical record review, it was determined the facility did not effectively integrate emergency services with all other departments and services to ensure that the emergency needs of all patients are met. This finding was evident in one (1) of 20 medical records reviewed. (Patient #8).

Findings include:

Review of the medical record for Patient # 8 noted that a [AGE] year old patient walked into the facility's ED on 2/29/2016, accompanied by her father with a presenting complaint of overdose. The patient was triaged on 2/29/2016 at 14:45 (2:45 PM) and was seen by a provider. It was documented in the ED encounter on 2/29/2016 that the patient resided with her father, as "the patient's mother is a drug addict."

The Behavioral Health Assessment, updated 3/1/2016 at 01:29 (1:29 AM), indicated that the patient's mother has an open CPS (Child Protective Services) case. It was noted the name of the CPS worker was not obtained. There was no documented Social Services intervention or reason noted why intervention was not necessary.

The patient returned to the ED on 3/1/2016 at 15: 37 (3:37 PM), with a chief complaint of passing out in school. The patient was accompanied by her mother.

There was no documentation that a referral was made by emergency department staff to the facility's Social Service Department to ensure a safe discharge. There was no documented follow up to verify coordination between the staff of the emergency and social services departments for assessment and follow up of this patient's high risk social and medical needs.

Based on medical record review, document review, videotape review, and staff interview, it was determined staff did not follow the facility's policies and procedures for: (a) Emergency medical care for a patient who presented to the facility and (b) assessment, treatment, and provision of appropriate follow-up care of patients with Emergency Medical Conditions. These findings were evident in six (5) of 20 medical records reviewed. (Patient #1, #3, #4, # 6, and #7).

A. The survey staff became aware that a Patient #1 presented to the facility and was transported to another facility to receive care.

Review of the Pre-Hospital Care Report Summary (PCR) dated 3/6/2016, noted the EMS unit responded to facility, with the reason "EDP - (emotionally disturbed - Psychiatric patient - Restraints required)." The patient (Patient #1) was found in hospital lobby, in a wheelchair and under police restraint (handcuffs). EMS transported the patient to another hospital facility.

On 3/23/16 at 11:00 AM, the surveyor interviewed Staff A, the triage RN on duty, 3/6/16. She stated Patient #1 was agitated, pacing in the ED waiting room. She asked the patient what she was in the ED for, but the patient would not come into the triage room. She also stated that she did not escalate this issue to the nursing supervisor, charge RN, or ED physician.

During interview on 3/23/16 at 11:30 AM, Staff B, Administrator On Duty on 3/6/16, confirmed that she was not notified until 1:03 PM, after notification by the hospital operators of a "disturbance" in the main lobby. She stated that when she arrived the patient was on the floor being restrained by three (3) guards. She was unaware that the patient had been in the ED waiting room prior to the event in the lobby.

On 3/24/16 at approximately 1:00 PM, the surveyor, reviewed the facility videotape, dated 3/6/16. Review of the videotape found: the patient was first seen wandering around the 1st floor of the hospital; passing through the ED waiting room; and entering a bathroom inside the ED waiting room. Patient then exited the bathroom accompanied by the triage nurse and two security guards and was escorted out of the hospital. Patient was seen re-entering the main lobby of the building, exhibiting agitated behavior, pacing, approaching patients, and attempting to pick up a trash can. Three (3) hospital security guards arrived immediately, and patient was taken down in the hospital lobby by the security officers and held down in a prone position (face down), on the floor for approximately 10 minutes, until New York City Police Officers arrived. Police Officer handcuffed the patient to the back, while kneeling on the floor. Emergency Medical Service (EMS) staff arrived approximately five minutes later, placed the patient in a wheelchair, and wheeled her out of the facility.

The action of the staff is not in consistent with the facility's policy for provision of Emergency care. The facility's policy titled "Emergency Treatment, Stabilization, Transfer of Patients and EMTALA," last Revised: 12/2012, noted that Emergency Medical Condition (EMC) is a medical condition manifested by acute symptoms of sufficient severity including psychiatric disturbances. The policy also stated that the facility will offer Emergency medical care to all individuals arriving at the hospital campus. The only exception is when the person makes an " informed refusal to consent to examination, treatment or transfer."

This individual walked into the facility in an agitated state and the ED staff did not offer and provide medical care in accordance with facility policy.

During interview on 3/23/16 at 2:00 PM, Staff F, Security Guard stated: Patient #1 was observed in the ED waiting room on 3/6/16, running around, yelling, screaming, and approaching other patients. He stated that "patient did not present for treatment and instead destroyed property and behaved in a manner that threatened the safety of staff, visitors, and others patients." The call to 911 was not for an ambulance but for Police Officer to arrest and remove the "subject."

At interview with security guards, Staff F and Staff G, on 3/24/16 at approximately 3:00 PM, it was stated that they did not receive any directive to escort the patient to the ED, even though the triage nurse and the Nursing Supervisor were present in the main lobby.

Review of the facility Quality Manager investigative report, dated 3/10/16, concerning the 3/6/16 incident, noted: At the time of the incident, the staff understood that the Police were the "authority" at the scene (lobby), and the Police made the decision to have EMS take the patient to Hospital B.

Consequently, hospital staff failed to intervene and re-direct the patient for emergency medical evaluation.

B.1. Review of the facility's central ED log on 3/22/2016 noted that a pediatric patient left without been seen. (Patient #3).
Review of the medical record for Patient # 3 noted documentation that provider care was initiated on 3/21/2016 at 14:55 (2:55 PM).
The ED provider note, updated on 3/22/2016 at 07:12 (7:12 AM), indicated the patient was a 1 year, 6 month old female and the chief complaint was documented. The disposition was "Left without Being Seen." There was no triage assessment or nursing assessment documented in the medical record.

Review of the medical record for Patient #4 noted the patient, a 12 year old, walked into the ED on 3/21/2016 with a chief complaint was difficulty breathing. The patient was triaged on 3/21/2016 at 10:55. The triage nurse noted "from school child with wheezing, completed prednisone 60 mg po for 3 days." The disposition noted, "left without being seen, saw a nurse but never saw a physician or midlevel provider."
It was noted that the initial nursing assessment did not include the patient's vital signs.

The Nursing Staff did not comply with the facility's policy titled "Triage-Emergency Severity Index (ESI) Policy," last revised on 11/12/15. The policy required staff to perform temperature, heart rate, respiratory rate, blood pressure, oxygen saturation level, and pain score on all patients, as part of a nursing assessment.
These findings were acknowledged by Staff G, on 3/23/2016, at approximately 4:00 PM.

B.2. Review of the medical record for Patient # 6 noted a [AGE] year old patient, with history of anxiety, asthma and depression, (MDS) dated [DATE], with chief complaint of lethargy/overdose. The patient received a medical evaluation and she was discharged from the ED on 2/29/2016 at 21:10 (9:10 PM).
The patient returned to the ED by ambulance on 3/1/2016 at 15:37 (3:37 PM), with a chief complaint of asthma and headache for one week. The patient was triaged on 3/1/2016 at 15:43 (3:43 PM). The triage nurse noted that the patient was brought in by ambulance; Emergency Medical Service Technician found the patient unresponsive at the scene. The vital signs were documented and a blood glucose result of 260 was also documented. (The normal blood glucose level (tested while fasting) for non-diabetics, should be between 70 to 100 mg/dL). The patient received a medical evaluation on 3/1/2016 at 16:33 (4:33 PM). The patient was discharged to home with diagnosis of anxiety.

It was noted that during the patient's ED encounter on 2/29/2016, the patient's blood glucose result was "H 117 mg/dl." During the patient's return to the ED on 3/1/2016, the patient's blood glucose was 260 mg/dl.
There was no documented treatment to address the patient's elevated blood glucose during both ED encounters and there was no documented follow-up treatment plan.
This finding was acknowledged by Staff H (ED Chairman), on 3/23/2016 at approximately 2:30 PM.

Review of the medical record for Patient # 7 noted this [AGE] year old patient, with history of drug abuse, was brought to the facility's Emergency Department (ED) by ambulance on 12/19/2015, with chief complaint of overdose. The EMS (emergency medical service) report indicated that the patient was found in a bathroom, unconscious. The patient reported that he used heroin. The patient was triaged on 12/19/2015 at 14:48 (2:48 PM) and a medical evaluation was completed on 12/19/2015 at 18:27 (6:27 PM).
The physician noted that the patient was given Narcan by EMS and became awake and "he now wants to leave." There was no documented evidence that the patient was offered or refused referrals for substance abuse treatment.
The patient was discharged on [DATE] at 18:43 (6:43 PM).

It was noted that this patient was given general emergency department discharge instructions and general instructions on Polysubstance Abuse. The Exit care patient information indicated that the patient was to see his primary care doctor in the next 24-48 hours for a repeat evaluation. There was no documentation in the medical record to establish that the patient had a primary care physician. There was no documentation that this patient was provided appropriate follow-up care on the patient's presenting drug abuse problem.

The facility's policy titled "Referral and Disposition of Patient for Follow up," last reviewed 1/16, indicated that in all cases where a patient requires urgent (24 to 72 hours) follow up, the ED physician shall contact the physician who will be providing the follow up care so that appropriate transfer of clinical information can be effected.
There is no documentation to indicate that the medical staff complied with this policy.