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Based on medical records reviews, policy reviews and interviews, the facility failed to protect and promote patient rights and ensure that patients received acceptable care in a safe environment.

Findings include:

1. Staff did not properly execute consent forms. See Citation at A 131.

2. The facility failed to develop and implement policies and procedures to ensure that all patient receive care in a safe environment. See Citation at A 144.

3. The facility did not develop and implement a system to ensure the monitoring of simultaneous use of both physical and chemical restraints. Furthermore, the staff were unaware that they were using chemicla restraints on patients which contradicts the facility's policy.
See Citation at A 160.

4. The facility's chemical and physical restraint orders were written inappropriately as standing orders or on an as needed bases (PRN). See Citation at A 169.

5. The facility failed to provide adequate education and training to all staff (including security) involved in the application of physical restraints. See Citation at A 202.

Based on the deficiencies cited under emergency services, it was evident that the hospital does not meet the emergency needs of the patients in accordance with standards of practice.

Cross reference is made to citations issued under the following tags #s A1101, A1103, and A1104 as follows:
-The hospital failed to develop procedures for triage by appropriately trained and qualified staff on a 24 hour basis;
- The hospital staff failed to develop appropriate oversight of staff who were found to sign off on incomplete Ambulance call reports ( ACR's)
- The hospital failed to implement procedures for the appropriate assessment and clinical interventions for psychiatric and medical patients in the ED;
-The hospital failed to ensure the timely provision of face to face consultations by qualified staff in the ED prior to patient discharge or disposition;
Refer to Emergency Services 482.55(a); 482.55(a)(2); 482.55(a)(3).
- See also citations written under Medical Staff 482.12(a)(5) in that the ED staff failed to intervene or have appropriate surgical coverage and failure to intervene clinically for ED patients.
-Also to citations noted under Patient Rights (482.13(c)(2)) is included in that violations of patients' rights occurred in the Emergency Department, including but not limited to, restraints by non-hospital personnel, failure to secure weapons brought into the ED.

A) Based on review of medical records, hospital documents and staff interviews, it was determined the governing body did not ensure its medical staff provided quality care that met acceptable standards of practice. (MR #3)

Findings include:

1) Review of MR #3 on 8/30/10 determined that the medical staff failed to adequately manage and treat a patient diagnosed with sigmoid volvulus in a timely manner.

According to the medical record, the patient presented to the Emergency Department (ED) on 3/12/10 at 2050 and was seen immediately by a physician because of the "high probability of imminent or life threatening deterioration in patient's condition." After being evaluated in the ED, the ED physician's clinical impression was Sepsis, Gangrenous bowel, Bowel obstruction, Volvulus, and Aspiration Pneumonia.

The plan for this patient was to admit to the Intensive Care Unit (ICU) and request an urgent surgical consult. According to the ED physician progress notes dated 3/13/10 at 0645, the surgeon was contacted by the ED physician and the surgeon "will operate if we can optimize the patient." The surgeon never arrived on-site at the hospital to evaluate the patient in person. The surgery was never performed because the patient expired on 3/13/10 at 0740.

2) During an interview with the Director of the ED on 8/31/10 at approximately 11:00 AM, it was stated that the staff in the emergency department would never attempt to use a sigmoidoscope to correct a volvulus and that there was no Gastroenterology coverage to perform an endoscopy on that date.

3) Review of the hospital's emergency on-call schedule for March 2010 revealed that from 3/11/10 through 3/14/10 there was no gastroenterology coverage for the emergency department. Furthermore, there was no gastroenterology coverage for the emergency department in 19 out of 31 days in March 2010.

B) Based on a review of the medical record, complaint log and hospital documents, the facility failed to provide gastroenterology services to patients in a timely manner. (MR #1 and #4).

Findings include:

1) a. Review of MR #4 on 8/30/10, determined that the patient presented to the ED on 3/5/10 with melena in the colostomy bag and anemia with a decrease in hematocrit. According to the facility's complaint log (Incident #10-31), a "GI consult called in on 3/6/10 at 0730" to a GI physician. "On 3/8 GI called again, was told he was at the hospital and will get back to us." On 3/8/10 at 1430, the GI physician called the unit and "said he refused consult over weekend and he is not taking consult." The hospitalist was "notified at 1630 on 3/8 of not accepting GI consult." Another GI physician was called at 1700 and again at 1745 on 3/8. The hospitalist finally spoke to a GI physician at 1800 on 3/8/10. The GI physician said that he "will see the patient in the AM on 3/9/10." No further action was taken by the ED or administrative staff and the endoscopy took place on 3/9/10. According to the medical record, the physician's orders for a GI consult was originally ordered on 3/6/10. A 3/6/10 progress note by the physician states "no EGD available until Monday" (3/8/10) "and that the son wanted the patient to be transferred to another hospital."

b. Review of the hospital's emergency on-call schedule for March 2010 revealed that from 3/4/10 through 3/7/10 there was no gastroenterology coverage for the emergency department.

2) a. Review of MR #1 on 8/30/10 revealed that the patient arrived at the ED on 5/1/10 at 0130 hours with intestinal bleeding. The patient was triaged as emergent and was seen by a physician "immediately on arrival because of high probability of imminent or life threatening deterioration in patient's condition." "BP on arrival was 60/30, he was diaphoretic and appeared to be decompensating." Various treatments were ordered and provided. The patient was not taken for an endoscopy on 5/1/10 until 0915 hours and to the Operating Room for an emergent gastrectomy at 1112 AM.

b. Review of the hospital's emergency on-call schedule for May 2010 revealed that from 5/1/10 through 5/3/10 there was no gastroenterology coverage for the emergency department. Furthermore, there was no gastroenterology coverage for the emergency department in 20 out of 31 days in May 2010.

C) Based on review of medical records and staff interview, it was determined that the hospital failed to develop effective procedures to ensure the safety and appropriateness of physician medication orders in the psychiatric emergency room.

Findings include:

1) Review of medical records on 8/30/10 revealed that the hospital utilizes standardized printed templates for physician orders in the psychiatric emergency room which contain inappropriately written orders that permit the prescriber to circle options to administer psychotropic medication as PO or IM. Furthermore, the form is written in such a pattern that the nurse could select the route.
Medical records contain a template form entitled "Physician's Orders -ER-HOLD-PSYCH ORDERS", which include pre-formatted orders for medication. The use of this form permits unsafe medication ordering and creates a high potential for errors due to unsafe medication administration practices.

Specifically, this form contains pre-printed list including, but not limited to, the following medications:
"Ativan____mg PO or IM Q 6-8H PRN anxiety
Remeron 7.5 mg PO QHS PRN insomnia/anxiety
Risperdal conc 1 mg PO TID PRN agitation
Prolixin 5 mg IM Q4H PRN agitation
Cogentin 1 mg PO/IM Q4H PRN EPS symptoms
Haldol ____ mg PO or IM once."

This format permits the prescriber to circle the option for the route of administration for Haldol, Cogentin, and Ativan. The ability to administer PRN Remeron, Risperdal, Prolixin, Cogentin, and Ativan leaves the decision to the nurse to medicate as needed. This form creates a strong potential for error in that it defers to the nurse the responsibility to determine the route of administration and frequency, which is out of the scope of nursing practice.

2) Interview with the emergency department Nursing Director on 8/30/10 at approximately 10:00 AM revealed the use of this pre-printed physician order template is standard in the psychiatric emergency room.

3) See also A160.

Based on review of medical record #1, there is insufficient documented evidence to show that the patient or his representative were given the information needed to make informed decisions regarding the patient's care and that consent forms were completed properly.

1) Review of the "Special Consent Form For Operation, Procedure and Treatment" form for MR#1 for the jejunostomy tube replacement procedure was not signed by the physician or a witness. The form was signed by the patient's spouse but was not dated.

2) Review of the "Special Consent Form for Operation, Procedure, or Treatment with Moderate Sedation" dated 5/3/10 at 1530 PM for Endotracheal Intubation/Bronchoscopy revealed that the form was not completed properly. The Consent for Procedure section was not signed by the patient or legal representative. However, the Consent for Moderate Sedation section was signed by the patient on 5/3/10. The physician signed but did not date either the Consent for Procedure nor for Moderate Sedation sections.

3) Review of the "Consent for Placement of a Peripherally Inserted Central Catheter (PICC)" revealed that the form was not completed properly. Item #8 on the form states, "I confirm that I have read and fully understand the above and that all blank spaces have been completed prior to my signing." Review of this form signed by the relative of the patient on 5/12/10 contains two blank spaces. The reason for the PICC line insertion was blank and the name of the person who will be performing the PICC line insertion was also not filled in.

Based on observations and staff interviews, it was determined the hospital did not develop and implement procedures and effective practices to ensure a safe environment of care for vulnerable patient populations served in the emergency department, including patients presenting with behavioral disturbances, prisoners, or pediatric psychiatric emergency patients.

Findings include:

1) a. The hospital did not implement effective procedures for the management of agitated patients and patients who are also prisoners under the custody of law enforcement officers.
During an interview with the Security Director on 8/31/10 at approximately 11:00 AM, it was stated that emergency department nursing staff frequently contact the Police for immediate intervention to help contain uncontrollable and agitated patients who require placement in restraints while in the emergency department. He stated that this practice was not endorsed by the facility and that it created confusion as the focus of law enforcement is different than his security staff. The hospital has no policy and practice for the criteria for referral of these matters to law enforcement. The existing restraint procedures do not address this contingency.

b. Review of the hospital's existing policy for "Prisoner and Inmate Control" on 8/31/10, determined there was no safety mechanism in place for prisoner patients placed in forensic restraints, such as handcuffs or shackles. On 8/31/10 at approximately 3:00 PM, the hospital's Security Director proposed and submitted a revised draft of its procedure during the survey to add the requirement that security staff shall ensure the point of attachment of handcuffs or shackles is secure, such as to a bed frame .

c. Review of ED policy and procedure title ED-P-P-0020 title blood alcohol and drug testing requested by police official on 10/27/10 found that under Part C, it was stated that the police will restrain the patient if necessary in order to obtain blood sample for alcohol and allegedly intoxicated patient. It did not specify the type of restraint that will be utilized and did not rule out the use of handcuffs and did not specify the role of hospital staff implementation of this restraint.

d. There was no evidence the facility formulated and implemented a policy and procedure to govern the activities of armed law enforcement in the ED with respect to safeguarding their weapons . On 10/27/10 at 11:15 AM in the Psychiatry ED, a Kingston Police Officer entered the area with his loaded gun in his holster and approached survey and hospital staff to inquire about a patient. At interview with Staff #2, it was acknowledged that there was no restriction of police officers carrying loaded weapons into the psychiatry department. He further stated that this represented a dangerous practice.

Based on review of medical records and policies and staff interviews, it was determined the hospital did not develop or implement a system to ensure the appropriate use or monitoring of simultaneous physical and chemical restraints. Even though the facility's revised policies prohibit chemical restraints, it was evident the hospital utilized medications as chemical restraints, for the purpose of controlling patient behavior.

Findings include:

1) Review of the hospital's current policy and procedure for "Restraint and Seclusion" in effect as of June 2010 determined that the hospital defines the use of chemical restraints but prohibits use of chemical restraints for behavioral health purposes. Review of the policy and procedure in effect at the time of the patient's (MR #2) admission for "Restraint Use", revised 3/18/08, determined that chemical restraints were permitted in that "orders for chemical restraints for patients with a primary behavior health need are PRN". No further instruction for safety or monitoring of chemical restraints was described in this policy. However, Risk Management staff stated, during an interview on 8/31/10, that they do not use chemical restraints in the hospital. The former policy as noted above allowed chemical restraints to be prescribed PRN.

2) Review of MR #2 on 8/30/10 determined the use of simultaneous physical and chemical restraints in a patient who subsequently expired. This 31 year old patient arrived at the facility's ED at 0740 AM on 1/2/10 with a diagnosis of Diabetic Ketoacidosis after having been transferred from another hospital. The patient's history was significant for schizophrenia. On arrival the patient was noted to be combative, lethargic, with shallow labored breathing. The patient's heart rate at 0740 AM on 1/2/10 was recorded at 149. He was medicated with Ativan 1 mg IVP and Haldol 3 mg IM for "restlessness" on 1/2/10 at 0755 AM.

3) There was ineffective management of the patient's medical and behavioral issues in that two drugs were utilized as chemical restraints in violation of standards for patient safety. These medications, Haldol and Ativan, were used to control patient behavior or movement and were not standard treatment for the patient's condition. Specifically, the physician authorized telephone orders of multiple doses of Haldol and Ativan on three consecutive occasions in less than a three hour period for this 31 year old male admitted for DKA, whose history was significant for schizophrenia. All three telephone orders lacked documented evidence of the reasons these medications were prescribed. A prior order written on 1/2/10 at 2 PM documented Lorazepam (Ativan) ordered 1 mg IV Q8H PRN for agitation.

a. Review of MR #2 physician order sheet dated 1/2/10 determined the physician authorized a telephone order to the nurse at 2330 hours on 1/2/10 for "Haldol 5 mg IV Q6 Hrs PRN". The nurse signed off on the order at 2350 hours on 1/2/10.
b. A second telephone order documented at 0115 hours on 1/3/10 noted "may repeat Haldol up to a total of 15 mg now-including 5 mg already given. Ativan 2 MG IV if Haldol (2) doses ineffective."
c. A third telephone order recorded at 0100 on 1/3/10 noted "Ativan 1 mg IV now (additional)."
d. The second and third telephone orders were signed off by the same nurse at 0140 hours on 1/3/10.

4) Review of MR #2 revealed that the physician's History and Physical note recorded at 1 PM on 1/2/10 states that at the transferring hospital prior to arrival at this facility, the patient received: 5-6 mg Ativan, 5 mg Valium, and 10 mg Haldol IVP.

5) a. Review of the medication administration record and physician's notes revealed that the patient received the following medications at this facility while in the ED on 1/2/10:
i) Ativan 1 mg and Haldol 3 mg IV at 7:58AM on 1/2/10.
ii) 1 mg Lorazepam (Ativan) and 15 mg Haldol was received in this facility's ED as recorded in the physician's History and Physical note recorded at 1PM on 1/2/10.
iii) At 5:30PM on 1/2/10, the patient received Ativan 1 mg IV push.
iv) At 11:30PM on 1/2/10 the MD ordered 5 mg IV Haldol ( per physician order )

b. The medication administration record in the ED for 1/3/10 noted the following:
i) On 1/3/10, the patient received 5 mg IV Haldol at 1:25 AM, and at 1:35AM
ii) On 1/3/10 at 0100AM the patient received Ativan 1 mg IV now.
iii) On 1/3/10, the patient received 2 mg IV Ativan at 1:30AM

6) With the exception of the order for Lorazepam PRN for agitation on 1/2/10 at 2 PM, none of these orders documented the basis or rationale for the medications prescribed. The ordering of Haldol PRN represents unsafe practice. The use of Haldol and Ativan at these dosages did not constitute a standard treatment for this particular patient's condition. These orders permitted the unsafe ordering of repeat doses of Haldol in a short time frame.

The wording of the second telephone order was unclear in that it suggested a second dose of 15 mg of Haldol could be administered and that Ativan could be added if it was determined the second dose of Haldol was "ineffective." The term "ineffective" was not defined and represented a strong potential for unsafe ordering and deferred medical duties to a nurse, which is out of the scope of nursing practice. The order as written deferred to the nurse the responsibility to assess the undefined order of "ineffective" and delegated the decision to nursing to provide additional medication.

7) During an interview with the pharmacist on 8/31/10 at approximately 11:00 AM, it was stated that the above order was written incorrectly in that the word "dose" should never be used in a written order and that only milligrams should be documented.

8) During an interview with nursing administration on 8/30/10 at approximately 3:00 PM, it was stated that the escalating doses of Haldol and Ativan were ordered because the patient (MR #2) had broken out of physical restraints. The use of these medications would make it less likely that he would break out of physical restraints again. Reference was made to a nursing note written on 1/2/10 that stated at 0140 hours patient became combative, pulled IV out, broke restraints and was attempting to leave. The facility's treatment for the patient's behavior was to give Ativan. The MD was called and ordered an increased dose of Haldol 5 mg. (IV), which was given, another Haldol IV given after MD called back, and another Haldol 5mg IV was given, followed by Ativan 2mg. IV given. These communications were by telephone.

9) After review of the medical record (MR#2) and staff interviews on 8/30/10, it was determined that the use of the medications for this purpose represent the inappropriate use of chemical restraints to control behavior or movement. The patient remained tachycardic and tachypneic despite these interventions until 0325 hours when a bradycardia ensued, followed by asystole unresponsive to ACLS intervention, including intubation which had been deferred for hours despite tachypnea and shallow respirations.

10) Review of the medical record (MR #2) determined no evidence of a face-to-face medical assessment by the physician to determine if the patient's response to the medications prescribed was appropriate. The staff failed to analyze the large quantity and dosage of medications delivered in the short time frame as noted above to prevent a strong potential for overdose.

11) The patient was also placed in simultaneous physical restraints between 0730 AM and 1515 PM on 1/2/10. A standing physician order was written on 1/2/10 at 0800 for bilateral wrist restraints for reason of risk of injury and to facilitate treatment. However this order was improperly written because it did not contain other least restrictive alternatives attempted prior to restraint initiation, was written as a standing order, and did not contain a time limit on the order as required by policy. Additionally, standing orders for restraints are not consistent with accepted standards of practice and should never be used for restraints.

12) Review of the patient's record revealed a "Psychiatric /Behavioral Health Restraint 4 hour flow sheet/log" form dated 1/2/09 (the correct date was 1/2/10), which contains a preformatted list of interventions performed every 15 minutes. There is no space dedicated for the provider to document individualized assessments on this form; there is space allocated only in each time slot for the assessor to document provider initials.

13) Review of the medical record (MR #2) revealed that the patient was given chemical restraints from 1/2/10 at 0755 AM until 1/3/10 at 0130AM. Vital signs were recorded in the medical record as performed on 1/2/10 at 7:45 AM, at 10:06 AM, at 12:59 PM and at 02:44 PM. Vital signs were taken every hour between 1/2/10 at 1615 PM to 1/3/10 at 0300 AM. On 1/2/10 at 1615 PM, the heart rate was 151, respirations at 42, blood pressure was 148/78 and oxygen saturation was 99%. On 1/2/10 at 1900 PM, the heart rate was 145, respirations at 43, blood pressure was not recorded and oxygen saturation was 95%. On 1/3/10 at 0100 AM, the heart rate was 133, respirations at 32, blood pressure was 177/134 and oxygen saturation was down to 86%.

14) The hospital was in violation of its existing policy and procedure for restraints in effect which required a face-to-face assessment within one hour after the initiation of restraints. Furthermore the policy in effect at the time did not specifically prohibit the use of restraints in the prone position. The patient expired on 1/3/10.

15) Review of the Code Blue Resuscitation Orders and Documentation Sheet on 8/31/10 found that the rhythm was noted as "asystole", and that the medical treatment included Narcan 0.4 mg IV (two doses) at 0325 and 0329 hours. This "asystole" was preceded by documented and untreated runs of Ventricular tachycardia and a severe bradycardia of 36 minutes prior to the event. The patient was on a telemetry unit.

16) a. The hospital's policy and procedures that were in effect on January 2010, and revised procedures on June 2010, do not give any instructions or parameters for use of simultaneous chemical and physical restraints used in the emergency room or inpatient medical units.
b. The former policy and procedures dated 3/13/08, only identifies the need for monitoring of trends related to use of psychotropic drugs instead of restraint or in order to allow a restraint to be discontinued.
c. There is no specific guidance provided to staff for the monitoring of patients given medications that are considered de facto chemical restraints for the explicit purpose of restricting movement or control of behavior that is not part of the standard treatment or dosing for the patient's condition.
d. The current policy and procedure revised June 2010, for restraints makes no reference to the restraint monitoring flow sheet as referenced in the previous policy. The only reference was made to the "OMH Restraint and Seclusion form," "restraint form or electronic medical record," which was not attached to the current policy and procedure.

17) a. Based on review of hospital forms, it was evident that the facility permits standing orders for physical restraints and that in one case, the physician pre-signed his name to a timed and dated order with no specific type of restraint checked off. (MR #1).

b. Review of MR #1 on 8/30/10, found that a form titled "Physician's Orders, Standing Orders for use of Restraints" was completed 5/4/10 and timed at 0700 hours and signed by the physician. It was incomplete in that there was no specific type of restraint ordered and no RN signature picking up the order. Therefore, this is charting in advance and gives the nurse the authority to determine the type of restraint to be used on the patient.

Physician's orders for the use of chemical and/or physical restraints must never be written as a standing order or on an as needed basis (PRN). See A 169.

Based on review of medical records and staff interviews, the orders for the use of physical and chemical restraints were noted to be written as standing orders and on an as needed basis (PRN). (MR #1 and #2).

1) Review of MR #1 and staff interviews revealed that a standing order for physical restraints was observed in the medical record. See A160.

2) Review of MR #2 and staff interviews revealed that chemical restraints were ordered on an as needed basis. See A160.

3) Review of MR #5 found a PRN restraint order written in the ED as follows: "Restrain patient to stop self excoriation if not able to talk down or chemically control behavior." This order was picked up by the nurse as valid. It did not define the type of (physical) restraint to be used and was contingent on the ability of the nurse to talk down the patient or control the behavior of the patient by the use of a chemical restaint. It did not state the medication that will be utilized as a chemical restraint. The order to restrain the patient was written at 7:30 AM, but the medications to be used as chemical restraints0 were written at 9:50 AM. Specifically it stated "if needed may repeat Haldol 5mg, Ativan 2mg, Benedryl 50mg IM or IV."

Based on staff interviews and review of policies and procedures and facility documents, it was evident that the security staff, who were engaged in the placement of patient restraints, were not trained in the application of physical restraints.

Findings include:

During an interview with the Director of Security on 8/31/10, it was stated that security officers routinely applied restraints and are trained to do so. It was stated that security staff apply physical restraints in addition to placing patients in manual holds.

When this employee was asked for the training provided to security staff, the Security Director submitted a roster of attendance of mandatory training for the Division of Criminal Justice Services (DCJS). This did not include specific training for the application of patient restraints and is generic for officers working in other industries, such as stadiums and malls.

This employee did not provide any documented evidence to show that these security staff had been formally trained on the safe application of patient physical restraints. The hospital is in violation of the current policy and procedure for Restraint and Seclusion, which requires staff to have physical restraint education and competency evaluations at orientation and on an annual basis. This revised policy does not include the need for training of security personnel.

Based on interview, review of documents, review of policy and procedure, it was evident the facility failed to formulate and implement the policy and procedure to ensure the accurate completion of ambulance call report (ACR) a.k.a. Patient Call Report (PCR) in the ED triage.

Findings incude:

During interview with Staff #2 on 10/28/10 at 11:00 AM, it was stated that the nurses electronically signed the PCR prior to the EMT completing the document. It was further stated that the completed ACR is faxed to the facility one hour after the triage nurses sign as hospital receiving agent.

At interview with Staff #2 at 1 PM, it was stated that the facility interpretated the signature on the ACR to be that the nurse received the patient only and it did not include the reading of any information provide by the EMTs on the PCR.

Review of ED triage policy and procedure found no reference of this practice of the nurse signing incomplete ACRs.

Review of Patient Care Run (PCR) #56144 for 10/21/10 found that the signature of the nurse on a portion of the PCR attested to the " acceptance of responsibility from the crew members ". The run corresponded to MR #5 for a gunshot wound to the abdomen.

A. Based on record review and interview, it was evident that the psychiatric consultations provided to patients in the psychiatric ED are done in a manner that does not provide sufficient documentation of clinical services provided or justificiation for discharge.

Findings include:

1. Review of medical record forms provided during the survey found that the forms state the names of the psychiatrist and the Nurse Practioner (NP) with the diagnosis and disposition written in by the Social Worker. The NP and the psychiatrist are located on the Benedectine Hospital campus and do not see the patients who are discharged. Those patients are discharged by the ED physician who may not have been the MD who saw the patient initially and may not know the patient.

2. At interview with the nurse practitioner on 10/28/10 at 1 PM, it was stated that she keeps no record of the substance of her communication with the social worker and maintains no log of the teleconference. The decision to discharge is not justified in any document prepared by the psychiatrist or the NP.

3. At interview with Staff #2 on 10/28/10 at 1 PM, it was acknowledged that no documention of the substance of the "assessment" by the psychiatrist or the NP is made part of the Kingston ED record or on any Benedctine Hospital forms. The forms used titled "Emergency Mental Health Assessment" is on Benedectine Hospital stationary even though it is completed at the Kingston Hospital.

4. At interview with Staff #6 on 10/28/10, it was stated that telephone orders are received by the NP or the psychiatrist from the Benedectine Hospital who do not see the patient and that these are routinely not co-signed until medical record chart completion reviews weeks later.



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B. Based on medical records reviews and interview, it was determined that the patient who presented to the ED with clinical evidence of a surgical emergency was not provided such services in a timely manner. There was evidence of a lack of integration of emergency, radiology, and surgical services.

Findings include:

1. Review of MR #7 on 10/28/10 found that the patient who presented to the ED with signs and symptoms of a surgical abdomen had surgery deferred from 2:20 PM (time of postivie CT) until 10:00 AM the following day. A CAT scan performed with the results of a ruptured appendicitis and abcess did not result in surgery until 10:00 AM the following day. There was a progress note and orders referring to a plan for a CT guided drainage of a pelvic abcess after a consult with radiology. There was no evidence of such consult or procedure.

2. At interview with Staff #2 at 10:00 AM, it was acknowledged that while the CT guided drainage was in a medical plan, there was no consult or such procedure and no justification for such an omission in the record.

3. Review of the ED record found that the first surgical consult was done at 9:29 PM, even though patient was triaged at 1:17 PM and the CT with evidence of surgical emergency at 2:20 PM.

Based on review of policies, interviews, and observations, it was evident that the facility included in process defined as "quick-registration" aspects of triage by other than qualified personnel.

Findings include:

1. The facility was observed having a person at a computer seated outside the triage booth facing the waiting room on October 27, 2010. At interview with Staff #2, it was stated that this person was the assigned the job of "quick registration" and that it included patient assessment prior to triage.

2. A job description was requested for Staff #2 and was not available onsite initially. It was located at Benedectine Hospital.

3. Review of the job description titled "Specialty Care Supply technician" on 10/28/10 found that originally there was no delineation of the job responsibilities that included documenting chief complaint as well as notification of the triage nurse of acute distress, including chest pain or stroke symptoms. This document originally was a Benedectine Hospital policy and was amended during the survey to include this accountability. .

4. Under essential job qualifications, NYS Paramedic and ACLS was noted. At interview with Staff #2, it was noted that the persons doing the quick registration do not possess that qualification. The specialty supply technican requests the patient to submit name, date of birth, chief complaint, etc.

5. Review of triage policy and procedure (ED PP0019) Triage/Assessment Updates on 10/28/10 found that from 10 PM until 10 AM there is no triage nurse in the booth but that security overhead pages or phones the nurse that a patient has presented.