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 and interview, it was determined that the hospital failed to maintain a central Emergency Department (ED) log, that was accurate and complete.

Findings include:

During a tour of the ED on 3/23/16 at approximately 11:00 AM, the surveyor reviewed the document titled "Confidential Patient Sign in Log." The log is a multi-use form with 20 "tickets". Each patient requesting care, is to compete a "ticket" (write his name, chief complaint, age and arrival time) and place the ticket in the "Mailbox" for the triage nurse to review. A new sign-in log is generated when the last ticket is used.

During interview with Staff A, triage nurse, on 3/23/16 at 11:15 AM, it was stated that the "tickets" become a part of the patient's ED record. The last page of the sign-in log, which has the names of all the patients who present to waiting room, are maintained by the facility. It was identified during the interview, that this patient sign-in log does not correspond to the facility's triage Register (the ED log) because the names of patients who presented to the waiting room and completed a "ticket" but walked out before triage, are not included on the facility's triage Register (ED log).

This is not in compliance with the facility's policy titled "Emergency Treatment, Stabilization, Transfer of Patients and EMTALA," last Revised - Reviewed: 12/2008, 12/2012, which states: the Emergency Central Log is a comprehensive record maintained of all individuals who come to the hospital seeking Emergency care. The Emergency Central Log includes patient logs from the emergency department as well as those patient logs from any other areas of the hospital.

During interview with Staff H, ED Chairman, and Staff G, ED Nursing Director, on 3/23/16 at 3:00 PM, it was acknowledged that while the sign-in logs are maintained, it is not the practice to incorporate the names of patients, who leave before triage, into the ED triage register.

Review of the "Emergency Department Triage Register," on 3/23/16 identified that the dispositions other than discharge and transfer, did not include patients who "left prior to triage." This finding was confirmed with Staff H and Staff G.
Based on document review and interview, it was determined that the hospital emergency department (ED) failed to provide a medical screening examination (MSE) , stabilize and appropriately transfer a patient who presented to the hospital. This was found for one (1) of one (1) patient(s) who presented to the hospital and was not afforded an emergency medical screening. (Patient #1).

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

Findings include:

The survey staff became aware that a patient presented to this hospital (Hospital A), and was transported to another facility and received care at that facility (Hospital B).

Review of the Pre-Hospital Care Report Summary (PCR) dated 3/6/2016, noted the EMS unit responded to Hospital (A) at 1313 hrs ( 1:13 PM ), with the dispatch time of 1245 hrs (12:45 PM), with the reason " EDP - ( emotionally disturbed - Psychiatric patient - Restraints required ) . The narrative history text for this event stated that the patient was found in the Hospital (A) lobby in a wheelchair and under police restraint ( handcuffs ). The patient was transported to Hospital (B) and arrived at 1:39 PM. (1339 hrs ).

During a tour of Hospital A, 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. She stated that she did not request that security escort the patient into the main ED for safe triage.

During interview on 3/23/16 at 11:30 AM, Staff B, Administrator On Duty on 3/6 /16, stated 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.

During interview on 3/23/16 at 2:00 PM, Staff F, Security Guard stated: Patient #1 (for whom there is no medical record and patient's name is not listed on the ED log) was observed in the ED waiting room on 3/6/16. Patient was running around, yelling and 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." The responding Police Officers, however, called for EMS to transport the patient form the hospital lobby to another facility (Hospital).

On 3/24/16 at approximately 1:00 PM, at the request of the surveyor, the facility acknowledged and presented the surveyor a copy of a 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; entering a bathroom inside the ED waiting room; exiting the bathroom accompanied by the triage nurse and two security guards and being escorted out of the hospital. Patient was seen re-entering the building and being in the main lobby, agitated, pacing, approaching patients and attempting to pick up a trash can. Three (3) hospital security guards arrived immediately, 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 Police Officers arrived. Police Officer handcuffed the patient to the back, while kneeling on the floor. Emergency Medical Service (EMS) arrived approximately five minutes later, placed patient in a wheelchair and wheeled her out of the facility.

At interview with Staff # and Staff G, security guards, on 3/24/16, at approximately 3:00 PM, it was stated that the patient was combative and required restraint. 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. They also stated that the restraint was not being performed so that the patient could be escorted back to the ED; It was to control behavior.

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.

Review of hospital EMTALA policy titled "Emergency Treatment, Stabilization, Transfer of Patients and EMTALA," last Revised - Reviewed: 12/2008, 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."
The facility failed to provided Emergency medical care to the patient, consistent with it's policy.

Based on medical record review and staff interview, the facility did not effectively meet the requirements for completing documentation in the medical records for patients who left the facility against medical advice. This was evident in one (1) of three (3) Emergency Department records reviewed. (Patient #2).

Findings include:
Review of the medical record for Patient #2 identified this [AGE] year old patient, with history of back pain and breast [DIAGNOSES REDACTED], presented in the facility's Emergency Department (ED) on 3/20/2016 with chief complaint of back pain. The patient was triaged and had a medical evaluation. The provider noted that the patient had a MRI (Magnetic resonance imaging) of the thoracic spine today and was sent to the ED for evaluation because of the finding of T10, 11 compression fractures with mild cord compression. The disposition - AMA (against medical advice).
It was noted that the documentation in the medical record did not include the examination or treatment that the patient refused. The risks/benefits of the patient leaving the emergency department was not documented in the record.
The patient signed the "discharged against Medical Advice Release" section of the "Consent for Emergency Treatment" form. The specific risk/benefits of leaving against medical advice, was not documented on the form. It was noted that the name of the provider was not included on the form.
The lack of documentation of the medical examination in the medical record and the incomplete AMA form were acknowledged by Staff I, ED Chairman, on 3/23/2016 at approximately 2:00 PM.

Review of the "Discharge Against Medical Advice Release" section of the "Consent for Emergency Treatment" noted that the form does not provide an area for the provider to specify the examination /treatment rendered, or a section for the provider to document the individual's risks/benefits.

During the exit conference, on 3/25/2016 at approximately 3:45 PM, the Staff I, Medical Director, acknowledged that there is no section on the facility's form for the provider to document each patient's risks/benefits for leaving against medical advice.