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Based on tours and observation conducted of the emergency department and labor and delivery area, it was determined the hospital failed to display adequate signs in all required locations of the emergency department, which specify the rights of patients to examination and treatment of emergency conditions and for women in labor in accordance with Section 1867.

Findings include:

The hospital did not post signs in all required areas which specify the rights of persons to access care for emergency medical conditions and for women in labor.

1. Tour of the ED adult treatment and ambulance entrance area on 12/29/10 at approximately 11:30 AM revealed there was no evidence that required signs were displayed in these locations.
Only one very large sign was posted in the triage booth area at the adult walk in ER entrance. This sign was posted in close proximity to the security desk located in the pre-triage area. No signs were posted in the ambulance entrance or treatment areas as required. Follow-up tour conducted by the surveyor at the ambulance entrance area on 12/31/10 at approximately 10 AM revealed that the sign had been placed in this location.

2. During tour of the New Life Center triage area and waiting room (labor and delivery) locations on 12/29/10 at approximately 1 PM, it was determined that no sign was posted to advise patients of their right to exam and treatment for emergency conditions including women in labor.

Based on observation and review of signage encountered during tours of the labor and delivery suite, it was evident the facility posted a sign that referred to insurance information for mother and baby, as well as photo identification, required for submission prior to admission or triage for labor and delivery.

Findings include:

During tour of the New Life Center triage area, a form was posted outside of the triage rooms entitled " Just a reminder", which required insurance information for the mother and baby as well as need for photo identification, during pre-registration and triage phases. Paragraph #3 of this form referenced that the gathering of correct information would ensure accurate insurance information. This practice might act to discourage patients from seeking emergency care.



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Based on review of documents, observations, and interviews, it was determined the facility engaged in a practice of registering patients and obtaining insurance information and evidence of identification prior to triage and medical screening.

Findings include:

1. During tour of the triage area and waiting room on 12/29/10 at around noon, blank forms were found on the security officer's desk located in the pre-triage area proximate to the walk in ED entrance and outside of the triage booth . This form was entitled " Patient identification and Verification form". This form directed the patient to provide the spelling of the patient's legal name, date of birth, social security numbers, and mother and fathers' first name in the space designated on the form. This was a duplicate: white designated chart copy and yellow was designated as the audit copy. These forms were present on the desk with the Emergency department patient sign in form, where patients are directed to record the reason for coming to the emergency room.

The form specifically stated that correct identification is the most important first step in patient registration. At interview with the security officer on 12/29/10 it was stated this form was provided along with the pre-triage assessment form in which the patient s notes their chief complaint on arrival.

At interview with the hospital administration, it was stated the form would be removed immediately. On follow-up tour of the ED on 12/31/10 at approximately 11 AM, the surveyor observed that this patient identification verfication form was removed from the security desk in the pre-triage area.

Review of all emergency department medical records reviewed during this survey for other reasons determined this form was used for all patients.

The practice of utilizing a form that requires patient identification by providing a social security number prior to triage might discourage patients from seeking emergency care. On 12/31/10 during the ED tour, a medical record (MR#2) was reviewed for an 11 year old child who arrived with a complaint of high fever, vomiting , dizziness, and headache, who walked out after triage and prior to registration on 12/22/10. The child was triaged at 11AM where it was noted the child had fever x 4 days, vomiting all night with no diarrhea. The temperature was within normal limits but no blood pressure was noted; the triage category assigned was ESI 4. It was evident that this patient identification form was completed prior to registration by the child's mother, who did not record the child's social security number on this form (MR #2).

Based on review of the emergency department log, it was determined the facility records information about patient insurance and documents classification of financial status for all patients seeking emergency care.

Findings include:

Review of the ED log on all dates of the survey found that the facility notes the financial class and designates insurance status for all patients referenced in a code format on the ED register log. The documentation of financial and insurance information for all patients is contrary to EMTALA requirements which require all patients to have access to emergency medical screening and treatment regardless of the ability to pay, payment source, or insurance status.


Based on review of the ED log, it was determined this log was incomplete in that it did not include an entry for an encounter on 9/17/10 for a patient who presented to the Emergency Department for treatment.

Findings include:

Review of the ED log for 9/16/10 through 9/18/10 revealed there was no evidence of documentation to reflect the first encounter that occurred on 9/17/10 by the patient referenced in medical record (MR #1). Additionally, there was a discrepancy noted in this medical record in that the stamp on the triage form noted 9/16/10 at 3:45 PM, whereas the remainder of this record reflected this visit documented the encounter of 9/17/10.

Based on review of procedures and documents, the facility did not perform a complete medical or psychiatric assessment for a patient who presented to the ED on two occasions for treatment. The facility does not have an effective system in place to ensure the complete screening of ED patients with evident psychiatric needs where the failure to provide a complete assessment creates a strong barrier to accessing medical care.
Findings include:
1. Review of MR #1 on 12/29/10 determined the facility did not provide a complete medical or psychiatric screening for a patient who demonstrated ongoing symptoms of paranoia, which limited her ability to access necessary diagnostic testing and medical care.

The staff failed to provide a complete medical assessment of this patient who presented with leg swelling on two occasions one day apart where there was a need to rule out DVT. The staff did not properly communicate the availability of ultrasound treatment which resulted in the patient's need to return to the ED a second time for medical intervention. During the first visit on 9/17/10, staff noted the patient expressed paranoid statements about health care workers but was not properly assessed for psychiatric needs where there was a reasonable concern that failure to do so would impede follow up care. The patient returned to the ED the next day because ultrasound services were unavailable.

Specific reference is made to the finding this patient presented to the ED on 9/17/10 at 3:45 PM for complaint of left foot swelling. During examination by the MD it was noted the patient was "repeatedly endorsing paranoia over fear of being harmed by healthcare workers." The psychiatric component of the ED medical assessment form recorded insight and judgment was circled as normal, affect was labeled as appropriate, and delusions was circled under assessment of thought. No further assessment of the patient's psychiatric status was noted in the medical record. There was no justification present to explain why a psychiatric consultation was not considered to further explore the presence of paranoid thoughts and delusions. Physical exam noted 2+ LLE edema. The physician documented a plan to obtain sono to rule out DVT but noted "unable to obtain a sonogram tonight".

The patient received an injection of lovenox 80 mg SC at 1655. The patient was discharged on 9/17/10 at 1736 with instructions to return the next morning to vascular lab for ultrasound examination of the leg at 9 AM the next morning.

The next morning the patient presented again to the ED on Saturday 9/18/10 and was triaged at 10:17 AM with a chief complaint of LLE edema and noted "for lovenox injection". The MD examined the patient at 10:55 AM and noted the patient had left ankle swelling and that she " was supposed to get a doppler today". There was no justification in the record to explain why the patient did not obtain the ultrasound exam. The second page of the medical assessment was incomplete. The staff examining the patient during the second 9/18/10 visit did not address the fact the patient was present in the ED one day prior or the concerns raised about her psychiatric status during that previous visit. The patient received another injection of lovenox 105 mg IM at 11:05 AM. The patient was discharged at 11AM on 9/18/10 with instructions to return the next day for injection and to come on "Monday morning" for vascular study (2 days later). A copy of a vascular lab ordering form for a left lower venous duplex for suspected deep or superficial phlebitis was attached to the medical record. There was no evidence to investigate the reasons for why the patient was unable to get the ultrasound, despite having been instructed to obtain this diagnostic testing.

Additionally there was no evidence of blood work performed for this patient during both visits to the ED. The staff administered medication without a diagnosis. There was no rationale or explanation noted in the record for the difference in lovenox doses administered during each ED visit and whether these variations in dosages administered were clinically appropriate or adjusted based upon the patient's weight and laboratory values.

The care provided to this patient was inadequate in that lovenox was administered with no medical diagnosis and without evident lab work to justify treatment. The patient also received different doses of lovenox medication on two occasions despite the finding the weight was unchanged. Staff continued to document instructions for ultrasound follow up for a patient who was at reasonably high risk for inability to adhere to follow up care recommendations, secondary to presence of delusions and paranoid thought as noted during the first ED visit. The continued referral for ultrasound, which was unavailable, may have contributed to her mistrust of medical staff and led to the inability to adhere to the treatment plan and need for diagnostic sonogram. Follow up interview with facility administrator on 12/31/10 found that the patient never returned for follow up to the outpatient sonogram department. The hospital failed to provide a proper medical screening for MR #1 in that they continued to treat the symptoms with lovenox without evidence of objective testing to support a diagnosis to rule out DVT, and by deferring the doppler examination, the patient was subjected to the risk of pulmonary embolism.

Interview with facility administrator on 12/31/10 reported that ultrasound services are unavailable round the clock and that patients presenting during non-business hours are instructed to follow up when the office is open. Interview with the facility's Medical Director on 12/31/10 acknowledged that patients who call to inquire about sonogram services are told to come in to the hospital but may not be advised that ultrasound services are available only during limited hours. It was also discussed that there were three complaints received from ED patients during 2010 involving the lack of availability of sonogram services at all hours. It was stated that improved efforts will be made to educate staff to accurately inform the public about the availability of services.

Review of the procedure for psychiatric consultations in the ER on 12/29/10 found that the policy did not clearly define criteria which would warrant the need for psychiatric assessment other than suicidality, prior suicide attempt within 30 days, and returns to the emergency department within 24 hours of receiving a prior psychiatric consultation. The policy indicates that consultation is at the discretion of the Emergency Department attending physician and focuses on actions to be taken when there is a difference of opinion between staff and psychiatric residents. Where there is the presence of homicidal ideation, violence, suspected impairments of thought, paranoid delusions, or disorganized behavior that could impede medical care access, the policy does not offer specific guidelines where consults would be strongly indicated.