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LONG ISLAND COMMUNITY HOSPITAL 101 HOSPITAL ROAD PATCHOGUE, NY 11772 Nov. 17, 2015
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on Medical Record review, document review and staff interview, the Emergency Department Staff failed to ensure:

1) Implementation of the facility's Policy, and to appropriately document the means of transportation for patients released from the emergency room resulting in a potential for patients to have an unsafe mode of departure home in two (2) out of six (6) Medical Records reviewed, 2) that patient / family consent was obtained for the patient to remain in the Emergency Department (ED) eight (8) hours after admission, or that the "Transfer Option" Policy was updated to reflect the current process, resulted in the potential for patients not being given the opportunity to transfer to another facility.

Findings:

1) Review of Patient #10's Medical Record (MR) revealed that the patient (MDS) dated [DATE] at 11:23PM by ambulance with altered mental status. The patient was documented to be yelling and incoherent with rambling speech. The Physician documented that "The patient was monitored closely overnight" and "Gradual improvement in exam and mental status over the evening". The Physician further documented "There are no significant changes from baseline labs". "He states that he (the patient) does not want to stay in the Emergency Department / Hospital", and that "The patient is able to ambulate and speak clearly at the time of discharge home".

The Nurse's Clinical Note documented at 6:58AM on 09/25/15 that "The Plan of Care was discussed with patient", "Patient discharged with printed instructions, verbalized understanding and able to comply". There is no documentation in the Medical Record regarding the patient's "Mode of Departure" which was listed in the Emergency Department (ED) Log as "Unknown".

Review of Patient #13's, Medical Record revealed that the patient (MDS) dated [DATE] at 12:16PM by ambulance after being in a motorcycle accident. The patient sustained road rash to multiple areas on her back and extremities and complained of right ankle pain. The patient's x-rays were negative and she was diagnosed with a strain and multiple abrasions / contusions.

The Nurse's Clinical Note at 3:03PM documents "discharged with prescriptions, given to patient and reviewed". "Patient verbalized understanding", and "Able to walk with safe steady gait on crutches, walking boot applied". There is no documentation in the Medical Record regarding the patient's "Mode of Departure", which was left blank on the Emergency Department (ED) Log.

On interview at 2:30PM on 11/17/15, Staff D stated that "The Nurse discharging the patient should be completing (documenting) the "Mode of Departure" in the ED Record and that "The staff should know that the patient has a safe way to get home".

During an interview with Staff K on 11/17/15 at 4:30PM, the staff member stated that the Nurse has to complete the Mode of Departure when the patient is discharged . They are instructed to choose the Mode from a drop down table that lists six (6) choices (air transport, ambulance, Police escort, private car, taxi or unknown)" and "When choosing unknown, they should document why in a Clinical Note".

The facility's Policy and Procedure (P&P) titled "Documentation for Emergency Department (ED) Discharge Patients", last revised on 08/31/15, directed Nursing Staff to document in the ED Chart the Mode of Transportation home, but lacked guidance that directed the Nursing Staff to document in a Clinical Note why the patient's the Mode of Transportation was listed as "Unknown".

2) During an ED tour on 11/16/15 at 1:30PM, Patient #4's wife approached the Nursing Station desk and asked Staff A for an update on her husband's inpatient bed assignment status. Patient #4's wife stated "My husband has been here for over twenty-four (24) hours and I do not know what is going on". Staff A stated she would find Patient #4's Nurse to update her. Patient #4's wife added "He had a bed assigned on a floor before but I do not know why it was taken away". When asked if anyone had spoken to them about their wait, or offered an alternative option, she stated "No, no we weren't".

Review of Patient #4's Medical Record identified that the patient had initially (MDS) dated [DATE] at 9:32AM with right-sided weakness and altered mental status. Patient was admitted at 12:21PM. Patient had been housed in the ED for twenty-five (25) hours and was awaiting a bed assignment on the 4th Floor Telemetry Unit for TIA (Transient Ischemic Attack) rule out / CVA (Cerebral Vascular Accident).

The findings were discussed with Staff Members A and D who both stated that they were not entirely clear on the Policy for admitted patients waiting in the ED.

Interview with Staff C on 11/16/15 at 2:00PM revealed that ED patients who are admitted and waiting for a Unit Bed assignment are offered the opportunity to transfer to another facility. Staff C stated that patients are offered a transfer option eight (8) hours after admission, then every twenty-four (24) hours thereafter while they remain in the ED. Staff C stated that the West End Unit Secretary offers the patient the option to transfer and then documents the patients' names and responses in a Log. The West End Unit Secretary then notifies the RN who is responsible for documenting a Note in the patient's Medical Record. The Logs are kept in a binder at the West End Nursing Station.

Document review of the ED admitted Patient(s) Eight Hours or Greater Data Log revealed the following:

Patient #4 was admitted on [DATE] at 12:21PM. He was first offered the option for transfer on 11/16/15 at 8:00AM, nineteen (19) hours and thirty-nine (39) minutes after admission. No RN documentation stating the patient had declined or consented to remain in the ED was found in the Medical Record.

Patient #11 was admitted on [DATE] at 7:29AM. He was first offered the option for transfer on 11/16/15 at 8:00AM, twenty-five (25) hours and thirty-one (31) minutes after admission. No RN documentation stating that the patient had declined or consented to remain in the ED was found in the Medical Record.

Similar lack of documentation for eight (8) hour transfer option offers were found in the Medical Records for Patients #5, #14, #15 and #16 for a review period of 11/15/15 to 11/16/15.

ED admitted Patient(s) Eight Hours or Greater Data Log pages for 11/10/15, 11/11/15 and 11/12/15 were not in the binder.

Interview with Staff B on 11/16/15 at 2:30PM revealed that Log Sheets should have been completed for those days. Staff B explained "When I'm here, I complete the Log. If no one is waiting, then I draw a line through it for the day. I don't know what happens on days that I am not here." This was confirmed with Staff C.

Patient Visits Lists for 11/10/15, 11/11/15 and 11/12/15 reflected the following:

On 11/10/15, out of thirty-three (33) total patients who presented to the ED, and were subsequently admitted , fourteen (14) patients were housed over eight (8) hours, four (4) patients were housed over twenty-four (24) hours and one (1) patient was housed over forty-eight (48) hours.

On 11/11/15, out of thirty-eight (38) total patients who presented to the ED and were subsequently admitted , thirteen (13) patients were housed over eight (8) hours and one (1) was housed over twenty-four (24) hours.

On 11/12/15, out of twenty-nine (29) total patients who presented to the ED and were subsequently admitted , five (5) patients were housed over eight (8) hours and one (1) was housed over twenty-four (24) hours.

These patients were not listed on the Log as having been offered the option to transfer (or consented to remain in the ED) until a Unit Bed was assigned.

The facility's Policy and Procedure (P&P) titled "Transfer of the Emergency Department Patient to Another Facility", last approved on 09/06/12, stated the following: "Patients / family shall be offered the opportunity for transfer if ... admitted to the Inpatient Service but are awaiting a specific bed assignment ... ", or "Consent to remain at BMHMC [Brookhaven Memorial Hospital Medical Center] secured ... ". This process will be repeated every twenty-four (24) hours while the patient remains in the ED.

The "ED admitted Patient(s) Eight Hours or Greater Data Log" stated the following: "The admitted patient(s) who are at the 8 [eight] hour mark will be offered the option to transfer to another hospital. Patients will then be offered an opportunity to transfer every 24 [twenty-four] hours after their first 8 [eight] hours of waiting for an admitted bed [as] follows: 1. The script above will be read to every admitted patient(s) who are at the 8 [eight] hour or greater mark by either the assigned Unit Secretary / Charge Nurse / Assistant Nurse Manager or Nurse Manager. 2. If the patient(s) accepts the option, the District Nurse is notified, who in turn will notify the patient's Physician, Case Management, and the Throughput Coordinator. Documentation must be provided in the Soarian System regarding the patient's request by the District Nurse. 3. If the patient(s) defers the option, the District Nurse will document the patient's decision in the Soarian System ... ".

The facility's Policy and Procedure (P&P) titled "Transfer of the Emergency Department Patient to Another Facility", last approved on 09/06/12, stated the following: "... It will be the responsibility of the ED Assigned Unit Secretary ... to offer the opportunity for transfer to ED patients who have been admitted but await bed assignment ... . The RN Logistics Throughput Coordinator will document the patient's response to the opportunity for transfer on the Eight (8) Hour Rule for admitted Patients Pending Bed Assignment Form. Each 24 (twenty-four) hour period will require a new form. Signed forms will be kept in the Medical Record."

During interview with Staff C on 11/17/15 at 10:10AM, when asked if this Policy reflected the current process, Staff C stated "No it does not. We no longer do it this way." She explained "This [Policy] is not correct. We use the Log. This form [the Eight (8) Hour Rule for admitted Patients Pending Bed Assignment Form] does exist and is given to the patient on admission, signed by the patient and added to the chart, but no one really reads this, so we started the Log instead. The new process is outlined in the Log Sheet. The process was changed because they needed someone who is here on a 24/7 (twenty-four hour / seven days a week) basis to do this." This finding was confirmed with Staff J.