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NYACK HOSPITAL 160 NORTH MIDLAND AVENUE NYACK, NY 10960 Oct. 5, 2018
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on medical record review, document review and interview, in one (1) of eight (8) medical records reviewed, it was determined the facility failed to ensure that staff conducted a behavioral health screen for a patient who presented to the Emergency Department (ED) with psychiatric crisis. This was evident for Patient #1.

Findings include:

Review of medical record for Patient #1 identified: Patient arrived by ambulance to the Emergency Department (ED) on 7/26/18 at 12:43 AM with altered mental state. Triage was conducted at 12:46 AM and a medical screening examination was conducted at 12:58 AM. Information obtained from contact with the patient's husband reported patient signed out of another psychiatric facility the previous day where she had been admitted for Depression on 7/12/18. The the patient was confused and was singing and walking around in the home naked in front of her teenage children and that she was refusing to take her medications. Due to the acute nature of the available information from the patient's prior medical record, the patient was placed on continuous observation by the physician.
At 1:10 PM, the physician noted patient initially refusing to allow blood draw but was otherwise calm. Ongoing treatment included supportive care. Second reassessment the patient noted, "patient is uncooperative with staff, bothering other patient and not abiding by simple requests to stop going into other patient areas. Patient becoming increasingly aggressive towards staff." Haldol 5mg and Ativan 2mg intramuscularly (medications for agitation) was ordered and administered by nursing staff them at 3:17 AM.
At 6:45 AM, the ED doctor reassessed the patient and noted she was asleep and in no distress, and at approximately 6:49 AM the patient was endorsed to the Physician Assistant (PA) and another ED doctor. The initial encounter physician's diagnosis: Acute Psychosis and Bipolar Disorder.


The accepting ED doctor documented that he reassessed the patient which revealed the patient was sleeping but easily awoken. "Patient states she was doing okay and was encouraged to eat the food at bedside. Waiting to be seen by psychiatric social worker." This provider's next entry noted the patient was psychiatrically cleared for discharge by psychiatric social worker working with the psychiatrist.

A Licensed Masters Social Worker (LMSW) documented an "Initial Screening Progress Note" at 10:13 AM, noting: ....Patient states "had a 'manic attack last night and started pacing. Patient said her thoughts mostly revolved around missing the Brooklyn area, where she used to live before coming to to Rockland County three (3) years ago. Patient is alert and oriented x 4, and presents with a clear and organized thought process. Patient denies SI/HI. Patient is requesting to go home." Collateral information was obtained from contacting patient's husband. The LMSW wrote that the clinical information was reviewed with the psychiatrist. Patient did not present with any acute psychiatric symptoms that would require an admission at this time. It is recommended that patient seek treatment at another academic institution that can offer intensive treatment for rapid cycling bipolar.

Documentation on the Nursing Assessment & Progress Notes states, patient was discharged from the ED 7/26/2018, at 9:56 AM.

The patient was taken back to the ED the next day, 7/27/18 because she "continued to display bizarre behaviors in the home." She was admitted to the Behavioral Health Unit that day with a diagnosis of Bipolar Disorder.



Review of the policy titled "Emergency Department-Psychiatric Assessment & Referral," which is not dated, states: "the triage nurse will notify the designated Qualified Mental Health Professional on call to perform a behavioral health screening for patients who present with psychiatric crisis."

The document, "Behavioral Health Initial Screening and Assessment" consists of eight (8) pages. There is no documented evidence that the Qualified Mental Health Professional completed this assessment.


During interview on 10/5/18 at 9:35 AM, the Licensed Masters Social Worker, acknowledged that she had not conducted the behavioral health screening and assessment but that she had only documented an initial screening progress note. Staff B confirmed that she had not read the ED nurses and physicians notes and that she was unaware of the patient's behavior which required Haldol and Ativan administration at 3:17 AM that morning.

Staff C, Psychiatrist who approved the patient's discharge on 7/26/18, stated during an interview conducted on 10/4/18 at 12:25 PM, that he did not examine or see the patient but that he had done a phone consultation for this patient. Staff C stated he was unaware of the patient's behavior at 3:00 AM that morning that warranted the administration of the medications.

These findings were shared with Staff A, the Interim Director of Quality, the CEO and Medical Director at approximately 2:00 PM on 10/5/18.