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 observations noted during tours conducted of the emergency department, it was determined the facility has restricted access to the facility by locking the ambulance bay door. This represents unsafe practice in that ambulance staff cannot gain access to the ED without a pass code and therefore creates a potential barrier in timely access to medical screening for patients in need of emergency care.

Findings include:

Tour of the emergency room on [DATE] at noon determined the facility has engaged in a practice of securing the ambulance bay doors in that these doors will not open and permit entry from ambulance docks without using a pass code.

Consequently an ambulance that is unfamiliar with the door access code would be unable to enter the ED in a timely manner, creating a potential for delay in medical screening and treatment. Additionally, this condition prevents persons who may present via private automobile from gaining necessary entry via the ambulance bay and would prevent the timely notification of emergency room staff upon arrival via car at the ambulance entrance.

Based on observations and review of statistical reports for emergency records, the facility engages in an unsafe practice of locking access doors to the ED to prevent unhindered entry and egress. This practice discourages patients from accessing emergency care and also prevents patients from leaving the ED unless staff assist in departures. In addition, the facility staff have also failed to take proactive actions to reduce the high incidence of patients who walk out prior to receiving complete emergency treatment.

Findings include:

Review of 2010 ED statistical reports on 2/15/11 found the following data for a large number of patients who walked out from the ED prior to completion of treatment :
August 2010; 215 walk outs;
September 2010; 193 walk outs;
October 2010; 189 walk outs;
November 2010; 260 walk outs;
December 2010; 256 walk outs;
January 2011; 278 walk outs.

It is impossible to explain the high incidence of patient walk out departures when all points of entry/egress to the ED are locked. One possibility remains that the walk out rate prior to treatment completion cannot occur unless these were staff assisted departures. Based on interviews with all emergency and administrative staff on 2/14/11, all emergency room doors are locked to prevent entry or egress from the ED. These doors can be opened only by staff ID access, which represents an unsafe practice and an impediment for patients seeking emergent care.

Based on observations made during tours of the emergency department it was determined the facility did not provide sufficient placement of signage in all required areas of the emergency room which specifies the right of all individuals, including women in labor, to receive examination and treatment of emergency medical conditions.
Findings include:
Tour of the emergency room on [DATE] and 2/15/11 at at approximately 10 AM found that while there was signage posted that specified the hospital's obligation to provide examination and treatment of all persons and women in labor, the placement of signage in required locations was insufficient.
While a total of six signs were posted, these existing signs were insufficient due to small size, small print, limited visibility, or were not prominently posted in all required locations. Posted signs must include all entrance, admitting areas, waiting rooms, and emergency treatment areas.
A total of six signs were identified in the emergency room in the following locations:
-one wall-mounted poster was noted in the pediatric waiting room and which was located in a subsection adjacent to the adult waiting room and separated by a transparent partition;
-two small signs were mounted on the wall and side partition of two registration booths, but were located only on the interior section occupied by hospital registration staff and not readily visible to patients;
-one sign was posted on the wall located in the internal ED treatment area immediately adjacent to the main doors leading from the walk in waiting room to the interior emergency room treatment area;
-one sign was posted in the waiting room in the psychiatric emergency room and a second was posted on the entry door of this waiting room.
With the exception of the pediatric wait area and psychiatric ED waiting room, existing signs were not readily visible. All signs were small, measuring approximately 8.5 X 11", and were written in small print in English only. Signs were not posted in other languages commonly spoken by patients utilizing the hospital.
Signs were missing from the following locations:
No signs were evident in the adult waiting room near the walk in entrance, pre-triage adult seating area near triage where a sign in form is maintained, and treatment areas in the internal main treatment area. No signs were evident at both the walk-in and ambulance entrances.

Based on review of the Emergency Department logs for 2010 and 2011 it was determined these did not contain complete or accurate disposition information for all patients who presented for care or who were evaluated in the emergency department.

Findings include:

1. Review of Emergency Department logs on 2/14/11 found these to be incomplete and inaccurate.
The hospital's ED uses a departure disposition code , "DEPE", which means the patient has been transferred to the emergency room from another part of the hospital, and the use of this terminology in the log does not represent a correct or accurate discharge disposition from the ED or hospital.
At interview with the Chief Quality Officer on 2/14/11 it was stated that the terminology , "DEPE", includes patients classified as those who are in fact transferred to the ED from another location of the hospital, such as the clinic, rather than where patients are discharged to when leaving the hospital. Therefore the use and classification of patients whose disposition is labeled as "DEPE" is incorrect as this terminology does not reflect the accurate representation of the actual disposition of the patient .

Specific reference is made to 4/4 applicable records for patients whose disposition was noted as "DEPE" as follows:

In MR # 14, this patient was seen on 11/6/10 and noted in the log to be DEPE disposition on 11/7/10, but in fact was discharged in improved condition. The actual detail of where the patient was discharged to was not specified in the record.

In MR #15, this patient was evaluated in the ED on 12/20/10 for abdominal pain and was noted to sign out AMA on 12/20/10 at 11:30 PM. However, this was inconsistent with and did not match the ED log in which it was noted the patient's disposition was classified as DEPE on 12/21/10.

In MR #16, this patient was assessed for shortness of breath on 12/20/10 and discharged to home. This was inconsistent with the disposition in the ED log which was recorded as DEPE.

In MR #17 this patient was assessed on 12/20/10 for lower abdominal pain and discharged to home. However, the ED log inaccurately classified the recorded disposition as DEPE on 12/20/10.

Therefore the log is unreliable and contains inaccurate documentation for patient disposition. Furthermore, examination of the mnemonic dictionary for discharge disposition does not contain a specific code for Child Welfare disposition and does not define the "other" category. The use of an "other" category does not meet the criteria for accurate disposition of patients.

2. Additional examples were identified for inaccurate disposition entries in the ED log that were inconsistent with medical records and which include:

In MR #6, a 2 year old child was brought in by Police and a family member for assessment of alleged child abuse. The ED log recorded the diagnosis as " Child Protective Services" and noted the departure disposition as "home", yet the record indicated the child left with a person noted to be an aunt and accompanied by Police. The medical record also noted the patient went home. The log did not utilize the term for law enforcement discharge ("LAW").

In MR #18, this patient who requested detoxification on 11/4/10 was noted to have been transferred to another facility. There were no transfer notes found. At interview with the Chief Quality Officer on 2/15/11 it was stated that the patient was advised to go to another facility where there were available beds for detoxification, but no formal transfer was arranged. The ED log noted the patient's disposition as "Oth", the mnemonic for "other".

In MR #22, the medical record noted this patient was discharged home on 11/4/10 with anxiety prescription. However, the ED log noted the patient's diagnosis of high blood sugar and documented the disposition of "oth" or other.

In MR # 25, reviewed on 2/15/11, the patient was brought in for violent behavior and hitting his head by EMS and Police. The patient was discharged on [DATE] at 2:30 PM. However the ED log indicates the patient was discharged instead to "LAW" at 1458 hours on 12/16/10. "LAW" is the pneumonic for discharge to court/law enforcement, according to the facility.

Based on observation , ED log review, and staff interview, it was acknowledged the hospital did not maintain a central log nor universally document all patient encounters/dispositions for correlation of all records in a central emergency log as required.

Findings include:

It was observed during the survey that three patient ED logs were maintained without appropriate integration for completeness and accuracy.
During tour of the ED on 2/14/11 at approximately 11 AM, it was observed that patients arriving at the walk in triage area signed in to a book noting "Emergency Department patient arrival log" . A column designated as "Q15 Chg Nurse /triage RN" contained check marks. It was later stated at interview with the security officer assigned to the ED triage area that he checks the form when the triage nurse sees the patient.
A second log titled "ED patient log" was maintained by support staff in the internal ED treatment area for active patients. It was stated by support staff and ED Administrative staff that this log is not the official one and that a third computerized log is considered a final log.
When queried about walk outs before and after triage, it was stated that the third and final official ED log might not contain the names of all persons who signed the first arrival log, especially if they walked out. Interview with the Chief Quality Officer and ED Support staff on 2/14/11 found that staff were unable to verify if all three logs were compared for inclusion and reconciliation of all existing names/patients. While some walk out patients might generate a face sheet of encounter, support staff remained unable to verify if all patients in the arrival log who left would generate a face sheet or be included in the third and final ED log.

Interview with Security and ED staff found that the practice of having all walk in patients sign an arrival log in the ED was stopped on 5/23/10 and was only re-started sometime around December 2010. Consequently the hospital had no formal record of any patients seeking treatment who left before triage or registration.

Interview with the Chief Quality Officer on 2/15/10 acknowledged that the tracking of walk outs before triage were not being recorded on the official log but that upon the implementation of a new system for "Mini-reg" planned on 2/25/11, this category will be included and tracked.

In three of three applicable instances, the ED log did not properly track or reference patients who accessed the emergency department for care.
Examples include:

In MR #s 9 and #10 , these patients arrived to the walk in ED for care on 2/14/11 and signed the arrival log at around 11:20 AM (12:20 was crossed out and 11:20 AM was written) and 11:18 AM, respectively. Follow up check with the Medical ED Director staff at approximately 1 PM found no record of either patient's presence in the ED or any record of disposition.

It was identified that for a patient referenced as MR #1, this patient had a substantial encounter with ED staff upon presentation for alleged complaint of chest pain on 12/21/10. The patient's visit was not concurrently recorded in any hospital document; this patient had walked out prior to being triaged on 12/21/10 and had no documented record of encounter in any log. There was evidence on a videotape of the ER as well as statements made during staff interviews, along with the hospital's records of investigation, that placed this patient in the ED waiting room on 12/21/10 requesting medical assistance.
Based on review of record and policy as well as staff interview it was determined the facility did not provide a sufficient medical screening examination to rule out child abuse in a toddler, who arrived to the ED for alleged abuse accompanied by Police and a family member. There was also no recorded evidence of completed interviews to identify the circumstances of the alleged abuse nor evidence of follow up with Child Protective authorities to ensure a safe disposition.

Findings include:

Review of MR # 6 on 2/15/11 found this 2 year old male child arrived to the ED at 2336 on 11/4/10 with a stated complaint of "Child Protective Services" and a chief complaint noted as "Alleged Abuse". The child was triaged at 2338 (11:38 PM) and classified as triage category ESI level 4.

The child received a medical screening exam at 12:30 AM on 11/5/10
but it was incomplete in that all elements of a complete exam were not performed. The sections on the medical pediatric injury T form for genital exam and rectal examinations were blank. The chief complaint noted by the MD was "no injury; needs check as sibling assaulted by mother." The historian was checked as the mother and Police. Caregiver denied past history.
The clinical impression noted was "well child -no signs of injury". The child was discharged to home in stable condition at 12:40 AM with instructions signed by a female whose name matched a copy of a driver license ID placed in the record. A medical follow up appointment was given. The maternal grand-aunt was the person whose driver license was copied and had signed the notice of privacy practice and discharge instructions.

During interview with the Chief Quality Officer and Director of Social Work on 2/15/11 at 3:55 PM, additional electronic nursing notes were provided to the surveyor that were not part of the original record. These notes included entries that recorded the child was brought in by NYPD (Police) and that the brother needed evaluation per ACS (Agency for Children's Services). There was no presenting physical problem noted nor visible injuries. Follow up nursing note at 0127 on 11/5/10 recorded that the child came in by EMS and was accompanied by an aunt and Police. The child was brought to the ER for medical clearance by ACS and was discharged by the MD. The child left the ED with the aunt and Police with no evidence of communication with ACS staff or clearance.

The hospital social worker contends there is no need for any further action since the child is known to Agency for Children's Services and children are brought in by ACS for only a physical assessment to be followed up by ACS. This response does not include the need for all elements of a medical and social assessment and established mechanism for communication of findings with ACS staff prior to discharge to establish safe disposition.

The record was incomplete in that there was no ambulance call report, no evidence of a complete examination to rule out all potential abuse , and no evidence of interviews to establish the circumstances around the allegations of abuse and to focus the examination. The identity of the family member was inconsistent; the MD noted the mother as the informant and alleged abuser, whereas nursing identified the person in attendance as the aunt. This also contradicted other documents noting this person as a maternal grandaunt. There was no evidence of any contact with ACS officials prior to discharge to assess safety or to clarify a safe disposition or follow up.

The facility's policy and procedure titled," Victims of Abuse" is insufficient in that it does not address instructions for actions required by staff when the child is escorted to the hospital emergency room for exam by law enforcement where ACS involvement is known, and when a protective custody hold is not initiated by hospital staff.
The policy does not clearly specify each action that must be taken to ensure ACS clearance prior to discharge from the emergency room in instances where a child at risk is not admitted for protective custody or medical issues.

The policy, however, does recommend that hospital personnel and ACS confer to resolve any differences in opinion related to termination of protective holds. There is no evidence that any process, including conferencing with ACS, was followed for the child referenced in MR #6.

Based on review of medical records, it was determined that the facility did not ensure the provision of timely medical screening assessments, which resulted in treatment delays, were not in accordance with prevailing standards of care. These findings were evident in 17 of 58 applicable records reviewed for medical screening exams.

Findings include:
a. Based on review of the documents, ED log, staff interviews, videotaped surveillance tapes of the walk in ED waiting room , it was determined the hospital failed to provide appropriate and timely triage and medical screening examination for a patient who arrived on 12/21/2010 at approximately 2255 (10:55 PM)with an alleged complaint of chest pain. (#1)

Findings include:
It was determined from review of hospital videotape surveillance and a complaint record that a couple who sought emergency care in the hospital on [DATE] had actually presented in the ED but failed to receive timely nursing or medical intervention. The patient is referenced as Medical record #1 but in fact never had a written record generated to document this encounter of the attempt to access emergency care. The patient and a companion left the emergency room without evidence of any interventions.

The following description of the hospital videotape corroborates the presence of a couple on 12/21/11 seeking emergency care in the hospital where it was observed immediate care was not provided:
Review of hospital surveillance videotape on 2/16/11 of the emergency department revealed a male and female walked in to the ED waiting room at approximately 22:55:15 on 12/21/10. The tape showed the couple interacting with the security officer. The security officer was observed opening the door of the main area of the internal ED treatment area and looking in but did not notice any communication with staff by the officer. The couple is then seen approaching the triage room, then seen on the tape approaching the main entry doors to the ED internal treatment area but did not enter. Additionally the couple is seen approaching the triage room a second time but did not enter. The couple is then seen leaving the ED waiting room at approximately 22:59:05, almost 4 minutes later.

Review of the hospital's documents on 2/16/11 determined the couple was in the ED for a total of about 7 minutes, which was not consistent with the four minute interval shown on the surveillance videotape. During interview with the security officer on 2/15/11, it was acknowledged the couple entered the ED where the male complained of chest pain. He advised the triage nurse, who was allegedly busy with another patient. Another male nurse came out from the ED treatment area and redirected the patient to wait for the triage nurse. During interview on 2/15/11 at approximately 3 PM with the triage nurse assigned to the ED on the date of the incident, it was stated that she recalled the patient had pushed the door, but she was with another patient. She told the patient to wait for one minute and that she would be right with them. When she came out approximately one minute later, the couple had left.

The hospital failed to implement a system to document the existence of the prospective patient, as the practice of having all patients sign an arrival log upon entry to the ED had been stopped in May 2010. Therefore there is no record of the patient's attempts to access emergency treatment or care in the facility other than the ED waiting area surveillance videotape and limited recollections of security and nursing staff interviewed. The hospital did not enact an effective policy and procedure to address patients arriving for emergent complaints (i.e.,. chest pain) where the triage nurse on duty are already occupied. In addition, the hospital's practice of locking the main entry doors to the ED internal treatment area may have provided an additional factor that delayed the patient in accessing emergency care. (See also citation under tag # 2400).

b. Based on record review and interview it was evident that the hospital failed to transfer a patient to a trauma center for emergent surgical intervention in that this facility does not have the capacity to emergently operate on a patient after a certain hour.
Review of MR#2 on found that the patient with multiple gunshot wounds to the abdomen who arrived in the ED at 9:11 PM and was triaged ESI #2 AT 9:13 pm was not taken to the OR for exploratory laparatomy until 11:00 PM. At operation 2 to 3 liters of blood (massive hemoperitoneum) were found in the abdomen. There was no evidence that transfer to a trauma center was considered. The ED ordered a CT and IV fluids, and waited for OR staff to arrive. At interview with the ED Med Director on 2/15/11 it was stated that after 7 PM the OR is closed and OR staff has to be called in from home. There is no trauma team per se, only a surgical consult and a CT was performed. During this period, the patient's clinical condition was deteriorating.

c. Based on record review and interview, it was evident that the facility attempted to transfer an unstable patient to 2 separate facilities.

Findings include:

Review of MR#3 on 2/15/11 found that the pediatric patient arrived in full traumatic arrest, being coded on and off (4 times) during the course of the ED visit.. The facility attempted to transfer this patient twice, once at 10:45 PM (called the trauma center twice and was refused as unstable) and once to a Long Island facility at 11:15 PM which requested a CT be done prior to transfer.

At interview with the ED attending on 2/15/11, he stated that the patient was unstable at all points during the ED visit. Therefore, any transfer would be unsafe. It is noted that the OR was closed at the time of the ED visit.

There was no evidence in the medical record of any consent for transfer. Review of the facility policy and procedure titled "EMTALA" under transfer, it states that a patient must be stabilized prior to transfer unless the physician certifies that the medical benefits outweigh the risks and that under section 2.1 of this policy that this certification must contain a summary of the risks and benefits upon which it is based. There was no note of any such certification in this medical record.

d. Based on record review and interviews it was evident that the facility did not perform a complete medical assessment on an elderly patient who was "pedestrian struck."

Review of MR#4 on 2/15/11 found that the elderly patient who was struck by an auto received an examination that was focused on the head injury, with no lab work ordered. The triage note referred to the complaint as an "MVA", not a "pedestrian struck", which has more critical clinical implications.

Review of the ACR found that the EMT's wrote "pedestrian struck" in their report . At interview with the triage nurse on 2/15/11 it was stated that she does not read the ACR (ambulance call report), only signs it.

e. Review of medical record #5 on 2/14/11 determined that the ED did not ensure the timely medical triage and placement of the patient in the psychiatric emergency department where the patient's affect and behavior could be monitored in accordance with standards of psychiatric practice. The patient remained in the medical ED with insufficient documented evidence of ongoing monitoring of behavior and affect. There was no evidence of medical orders for one to one monitoring nor flow sheet of one to one observation.

Specific reference is made to this record of a [AGE] year old female with self inflicted superficial left wrist laceration, who arrived at facility on 2/13/11 at 4:44 PM by EMS. According to the ambulance call report, patient was not triaged by the facility staff until 5:34 PM. There was no explanation noted for this delay between the time of arrival to the ED and triage. In addition the ACR arrival time of 4:44 PM was in discrepancy with the record, which noted the patient's arrival time as 1729 (5:29 PM).
The patient was triaged in the medical ED at 5:34 PM and rated as triage category ESI level 2. She was assessed by the MD at 5:50 PM who noted application of steristrips. The patient was held in the medical ED for a protracted period and was not medically cleared for psychiatric until 10:15 PM. Although numerous nursing notes make reference to one to one monitoring in the medical ER , there is no supporting documentation of a flow sheet that described the behaviors nor evidence of medical orders for one to one observation. The medical record did not adequately describe the interventions in the medical ED that warranted a stay of greater than 8 hours in the medical ER.
The patient was not transferred to the psychiatric ED until 2:05 AM on 2/14/11.

The patient was admitted to inpatient psychiatric unit at 0435 am on 2/14/11.

At interview with the Senior Vice President and Chief Quality Officer on 2/14/11 it was stated that a one to one monitor is not necessary in the medical ED because all of the exit doors from the ED are locked. This response does not address the applicable needs of the patient such as ongoing continuous assessment of affect and behavior.

f. Based on record review and review of the ED log, it was evident that a patient with chest pain who arrived at 11:55 AM on 11/4/10 and was assigned a triage rating of ESI 3 was noted as a walk out on 11/5/10 at 0028 hours (12:28 AM). Review of MR #24 finds no evidence that this patient was ever assessed by a physician for chief complaint of chest pain radiating to the back.

g. Based on review of medical Record #12 and the ambulance call report for a patient who presented as found on the sidewalk possibly intoxicated, it was noted the EMT's timed their arrival at the hospital as 1554 hours (3:54 PM) and yet it was noted on the hospital record that the patient arrived at 1639 hours and was triaged as 1640 hours. The patient was not assessed by the physician until 1710 hours (5:10 PM). The patient was assigned an ESI rating of 2 and was therefore classified as urgent status.

h. Review of MR #7 on 2/14/11 determined this patient, who presented with chest pain, arrived at 11:03 AM and was triaged at 11:05 AM on 2/14/11, but was not seen by a physician until 12:10 PM. An EKG was not performed until 11:28 AM. Although the patient was discharged by the resident physician, the attending faculty note was signed but was blank, with no disposition or time recorded.

i. Review of MR # 8 on 2/14/11 who was transported by EMS from a nursing home for a blocked A-V graft in the left arm. The medical record stated she arrived at 1559 and was triaged at 1604 hours and yet the ACR notes the patient arrived at 1512 hours. This discrepancy was unexplained in the record. This patient was assigned an ESI level 2, which is an urgent category.

j. Based on review of MR #26 on 2/15/11, it was evident that the patient who was treated for [DIAGNOSES REDACTED] with an injection did not receive a reassessment to determine the effectiveness of the treatment prior to discharge.

k. In Medical record #23, where the patient's complaint was urinary retention on 11/3/10, there is no evidence of a complete assessment of the amount of urine in the patient's foley catheter and whether or not the patient had arrived to the ER with a foley catheter. This did not evidence a complete medical assessment of the patient's chief complaint of urinary retention.

l. In MR # 19 it was evident that the patient, with a history of cardiac catheterization with stent and who was taken to the ED by EMS on 2/13/11 for chest pain, was assigned a triage category of ESI 3 . Although the patient was triaged at 2315 she was not assessed until 2350 by the physician. The patient was admitted for acute coronary syndrome.

m. Review of MR #20 on 2/15/11 indicates the patient arrived in the ED on 11/1/10 at 1344 and was triaged at 1345 with an ESI rating of 4. The chief complaint was listed as "laceration- suture." There is no note as to the mechanism of injury, or the extent of the laceration. The only note, other than the triage, is a handwritten entry on the registration sheet, stating "NR -8PM", which indicates the patient was called at 8 PM for treatment. This constitutes a wait of 6 hours and 15 minutes.

n. Review of MR # 21 on 2/15/11 determined the patient arrived on 11/1/10 and was triaged at 1548 with a chief complaint of abdominal pain rated with a pain scale of 10/10. The patient was never seen by a physician and was noted as having left the ED at 1735 hours. The patient was rated as triage category ESI 3.

o. Review of MR # 11 found this patient, who presented three times in the same day on 2/14/11 for emergency care, was not appropriately screened for evident psychiatric needs.
This patient (MDS) dated [DATE] via EMS for back pain. The patient was noted to be "drug abuse" and also taking medications including diazepam and olanzapine. The ED log noted patient was no response at 0421 AM. The patient presented a second time to the ED at 0847 AM on 2/14/11 with a chief complaint of pain to the spine for one day. Pain intensity was rated on a scale of 9/10 and the patient was improperly triaged as a ESI level 4. The patient answered yes to questions on a suicide/homicide screening tool at triage , including affirmative answers to questions such as feeling he would be better off dead and having thoughts of harming himself and others. The patient was assessed by the PA and MD, where sections for neuro/psych was checked as negative. This discrepancy between assessment for psychiatric status was not addressed. The patient was given an injection of toradol and advised to return to surgery clinic the next day and was discharged at 11:52 AM on 2/14/11. The patient returned a third time to the ED on 2/14/11 at 1425 requesting detoxification from alcohol and cocaine. The patient was admitted for detoxification.

p. Review of MR #22 on 2/15/11 determined this patient did not receive a sufficient medical or psychiatric screening exam for identified needs. The [AGE] year old patient was brought by ambulance on 11/3/10 for complaints of elevated sugar, palpitations, and breathing difficulty. She was also crying and hyperventilating prior to arrival. Past history was significant for diabetes, past cardiac catheterization, and anxiety. The patient's chief complaint was only indicated as high blood sugar per patient; fingerstick at triage was 290. The emergency physician noted the patient is tearful and anxious and had run out of medication because the doctor was on vacation. Patient was noted as tearful with a past history of anxiety and depression and taking elavil and xanax. The patient was provided with xanax and discharged home in stable condition . Anxiety Prescription was recorded on the clinical impression and disposition summary but the specific medication prescribed was not recorded. While the patient was noted as improved, the specific response to the medication administered was not recorded nor the justification for the lack of formal psychiatric assessment. There was no evidence the medical screening addressed the elevated glucose.