A. Based on a review of medical records, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to follow its policy regarding the transfer of patients. Findings include: Reference: Facility policy 3.217 EMTALA, states, "... 2. Whenever a patient with an Emergency Medical condition is transferred to another facility, a New Jersey Universal Transfer Form must be completed... If the patient (or a legally responsible person acting on behalf of the patient) is first fully informed of the risks, benefits and alternatives and their risks and benefits to the transfer... the transfer may occur if... ii. Acknowledges his/her request and understanding of the risks and benefits of the transfer by signing the New Jersey Universal Transfer Form. ... ." 1. Review of Medical Record #3 on 1/6/17 revealed the patient arrived at the ED (Emergency Department) on 7/30/16 at 1:50 PM with complaints of a seizure. a. The patient was transferred to another facility at 9:42 PM. No evidence of the New Jersey Universal Transfer Form was found in the medical record. b. Upon interview, Staff #1 indicated that the facility uses a Transfer Consent Form for transfers out of the ED. c. The Transfer Consent Form in Medical Record #3 was missing the following information: date/time of report, name & title of accompanying staff, any additional equipment, and RN signature attesting to medical records accompanying patient. 2. Review of Medical Record #2 on 1/6/17 revealed the patient arrived at the ED on 9/24/16 at 7:33 AM with complaints of altered mental status, s/p (status post) fall. a. The patient was transferred to another facility at 4:42 PM. No evidence of the New Jersey Universal Transfer Form was found in the medical record. b. The Transfer Consent Form in Medical Record #2 was missing the following information: Patient condition, vital signs at discharge, RN accepting report, date/time of report, receiving facility phone number, and RN signature attesting to whether medical records are accompanying the patient. 3. The facility failed to use the New Jersey Universal Transfer Form for ED transfers as specified in the above policy. 4. The Transfer Consent Form was incomplete in Medical Record #2 and #3. 5. Staff #1, Staff #2, and Staff #3 confirmed the above findings. B. Based on review of medical records, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to follow its policy regarding patients leaving against medical advice and elopement. Findings include: Reference: Facility policy 1.210 Leaving Against Medical Advice and Elopement, states, "... A. For patients requesting to leave against medical advice (AMA): 1. The physician and nurse will explain to the patient the risks of leaving against medical advice. 2. If the patient insists on leaving, the patient will be asked to sign the Release of Liability Form. a. For an emergency room or CDU patient, this release is on the back of the emergency room face sheet. ... 4. In the event that the patient refuses to sign the release, document the refusal in the patient's medical record. ... B. For patients noted to be unaccounted for or have eloped: 1. Initial Notification: a. When a patient cannot be unaccounted (sic) for, staff will immediately notify the patient's nurse/charge nurse. b. Patient's RN/Charge Nurse contacts the Clinical or Department Director and/or the Clinical Operations Director and provides a description of missing patient and safety concerns/medical issues. c. The Clinical Director or COD shall notify security. ... ." 1. Review of Medical Record #10 on 1/6/17 revealed the patient arrived to the ED on 4/25/16 at 8:38 AM with complaints of bilateral arm numbness and blurred vision. a. The patient left against medical advice (AMA) at 3:59 PM. b. The medical record lacks evidence of a signed Release of Liability form indicating the patient was leaving against medical advice. c. The medical record lacks evidence documenting the patient's refusal to sign the Release of Liability form. d. The facility failed to follow its procedure regarding a patient leaving AMA. 2. Review of Medical Records #11, #15, and #29 on 1/6/17 revealed the patients eloped from the ED and were unaccounted for. a. Medical Records #11, #15 and #29 lack evidence of staff notification of the Clinical Director or Security of the patient's elopement, as referenced in the above policy. 3. Review of Medical Records #4, #7, #9, #12, #21, #23, and #24 revealed the patients left without treatment (LWOT) from the ED and were unaccounted for. a. Medical Records #4, #7, #9, #12, #21, #23, and #24 lacked evidence of staff notification of the Clinical Director or Security, that patients were unaccounted for. 4. The facility failed to follow its policy regarding the patients who are unaccounted for. 5. Staff #1, Staff #2, and Staff #3 confirmed the above findings.

Based on observation, staff interviews, and review of facility policy and procedure conducted on 1/4/17 and 1/6/17, it was determined that the facility failed to conspicuously post signage, specifying the rights of individuals under section 1866 of the Act with respect to examination and treatment of emergency medical conditions and women in labor. Findings include: Reference: Facility policy 3.217 EMTALA, states, "... H. Signage: 1. CUH (Cooper University Hospital) shall post signs in conspicuous locations likely to be noticed by all individuals entering DEDs (Dedicated Emergency Departments), Labor and Delivery areas and other areas where patients are screened (including areas such as entrances, admitting areas, waiting rooms, treatment areas) specifying the rights of individuals under EMTALA with respect to examination and treatment for emergency medical conditions and women in labor. 2. CUH shall conspicuously post signs indicating that the hospital participates in Medicaid. 3. The signs shall be posted in English and Spanish. ..." 1. Observation of the ED walk in entrance, the ED ambulance entrance, the Keleman walk in entrance, the Clinical Decision Unit (CDU) entrance, the main hospital entrance, and the parking garage entrance revealed no signage posted. 2. Observation of the ED revealed the following: a. Pediatric Resuscitation Room 3A had no signage posted in English. b. Pediatric Resuscitation Room 3B had signage that was covered by a closet door. c. Bays/Rooms 9B, 10 through 19, and 23 had no signage posted. d. Hallway stretchers E, F, TH1, TH2, and TH3 had no signage posted. e. Rooms 30 and 38 had no signage posted in Spanish. f. The Consult Room had no signage posted. 3. Observation of the Fast Track waiting area and hallway corridor revealed no signage posted. 4. Observation of the CDU revealed the following: a. Room 913 A & B (C Hallway) had no signage posted. b. Room 914 A & B (B Hallway) had no signage posted. c. Room 915 A & B (A Hallway) had no signage posted. d. Room 917 A & B (CDU 1) had no signage posted in Spanish. 5. Observation of Obstetrics Triage rooms 603, 604, 605, 606, and 609 revealed no signage. 6. The above findings were confirmed with Staff #1, Staff #2, and Staff #3.

A. Based on staff interviews, medical record review, review of the ED log and facility documents conducted on 1/6/17, it was determined that the facility failed to maintain an accurate ED log that identifies the discharge disposition. Findings include: Reference: Facility policy, 3.217 EMTALA, states, "... IV. Policy...F. Individuals Who Have An Emergency Medical Condition But Refuse To Consent To Treatment Or To Transfer... 3... Recordkeeping...iii....I The Central Log shall include the patient's name and outcome and indicate whether the individual: a. refused treatment (whether left without being seen-LWBS, or against medical advice- AMA... ." 1. The ED log for Medical Record #10, date of service 4/25/16, indicated the ED discharge disposition was "discharge to home." a. Medical Record #10 indicated that the patients' discharge disposition should have been "AMA." 2. The ED log for Medical Record #11, date of service 4/25/16, indicated the ED discharge disposition was "discharge to home." a. Review of Medical Record #11 indicated that the patients' discharge disposition should have been "Eloped." 3. The ED log for Medical Record #15, date of service 4/25/16, indicated the ED Discharge Disposition was "AMA." a. Medical Record #15 indicated that the patients' discharge disposition should have been "Eloped." 4. The ED log for Medical Record #21, date of service 6/26/16, indicated the ED discharge disposition was "AMA." a. Medical Record #21 indicated that the patients' discharge disposition should have been "Left without treatment (LWOT)." 5. The ED log for Medical Record #29, date of service 10/29/16, indicated the ED discharge disposition was "AMA." a. Medical Record #29 indicated that the patients' discharge disposition should have been "Eloped." 6. The facility failed to follow its EMTALA policy and procedure. 7. The above findings were confirmed with Staff #1 and Staff #21. B. Based on staff interviews, review of facility policy and procedure, and review of the Labor and the Delivery (L&D) Daily Log, it was determined that the facility failed to maintain an L&D log since October 2016. Findings include: Reference: Facility policy 3.217 EMTALA states, "... IV. Policy...F. Individuals Who Have An Emergency Medical Condition But Refuse To Consent To Treatment Or To Transfer... 3... RecordKeeping:...iii. An EMTALA Central Log shall be maintained in the DED or other area, such as Labor and Delivery/OB Triage, where an individual may present for emergency services or have and MSE... ." 1. On 1/4/16, the L&D Triage Unit was toured, and Staff #14 confirmed that with a change of the computer systems in November of 2016, the OB Triage Log has not been maintained since October 2016. 2. The last entry date on the OB Triage Log provided by Staff #14, was 10/26/16. 3. Upon interview, Staff #6, the Clinical Director of the ED, stated that OB patients (that fit the criteria; 16 weeks or greater gestation or 6 weeks or less post partum) that come in through the ED are not reflected on the ED Log if they are sent to OB triage. 4. The facility failed to follow its EMTALA policy and procedure as referenced above. 5. The above was reviewed and confirmed with Staff #1.

Based on medical record review, review of facility policies and procedures, and staff interviews, it was determined that the facility failed to ensure all patients receive appropriate assessment, management, and treatment of pain. Findings include: Reference #1: Facility policy, Pain Management, states, "... Work together with the patient and family and other health care providers to develop and implement a plan for pain relief. ... 3. Based on the patient's self-report and ongoing assessment findings, a treatment plan shall be initiated. ... 4. Pain shall be reassessed after each intervention once a sufficient time has elapsed for the treatment to reach peak effect. ... ." Reference #2: Facility policy, Pain Management (Patient Care Services), states, "... 4. Pain management interventions shall be initiated whenever the patient scores a pain rating greater than zero. ... 1. Ongoing reassessment of pain is at least every visit and after pain management intervention for outpatients. ... Documentation of reassessment of pain shall be noted to reflect the time of reassessment after intervention(s) and prior to discharge/end of visit for outpatients. ... D. Provide interventions to reach the patient's acceptable level of pain using pharmacologic and non-pharmacologic interventions. ... ." 1. Review of Medical Records #8, #17, #18, and #19 on 1/6/17 revealed the following: a. Medical Record #8 indicated the patient arrived at the ED on 4/25/16 at 5:25 PM with a complaint of vaginal pain for three (3) weeks. i. On 4/25/16 at 6:06 PM, the patient's pain level was assessed at nine (9) out of ten (10) on the facility's numeric pain scale. ii. On 4/26/16, at 1:15 AM, the patient's pain level was re-assessed and remained nine (9) out of ten (10). iii. The Medication Administration Record indicated Morphine 2 mg IV (Intravenous) was given at 1:15 AM. This was seven (7) hours and fifty (50) minutes after the patient arrived to the ED. iv. Medical Record #8 lacked evidence of the initiation of a pain treatment plan. v. Medical Record #8 lacked evidence of the use of non-pharmacological interventions to manage the patient's pain. b. Medical Record #17 indicated the patient arrived at the ED on 6/26/16 at 7:51 AM with complaints of nausea and vomiting for two (2) days and abdominal pain. The patient is seventeen (17) weeks pregnant. i. On 6/26/16 at 9:10 AM, the patient's pain was assessed a ten (10) out of ten (10) on the facility's numeric pain scale. ii. Medical Record #17 lacked evidence of the initiation of a pain treatment plan. iii. Medical Record #17 lacked evidence of a reassessment for pain prior to discharge. c. Medical Record #18 indicated the patient arrived at the ED on 12/27/16 at 3:48 PM with a complaint of abdominal pain s/p (status post) fall. Patient is twenty-four (24) weeks pregnant. i. On 12/27/16, the patient arrived at the OB triage unit at 4:15 PM. The triage RN states, "... presents with pain following a fall onto her back in the evening on 12/26. Assessment completed as per flowsheet. ... ." ii. Review of the patient's flowsheet for 12/27/16 revealed that the initial assessment of the patient at 4:35 PM did not indicate a numeric pain level. iii. On 12/27/16 at 6:42 PM, the patient's pain was assessed at seven (7) out of ten (10) on the facility's numeric pain scale. iv. Review of the patient's medication administration record for 12/27/16 revealed Tylenol 975 mg tablet was ordered at 6:10 PM, however, there is no indication that the patient received the medication. v. Medical Record #18 lacked evidence of initiation of a pain treatment plan. vi. Medical Record #18 lacked evidence of a reassessment for pain prior to discharge. d. Medical Record #19 indicated the patient arrived at the ED on 6/26/16 at 6:15 PM with a complaint of abdominal pain. The patient is seven (7) weeks pregnant. i. On 6/26/16 at 6:27 PM, the patient's pain was assessed at ten (10) out of ten (10) on the facility's numeric pain scale. ii. Medical Record #19 lacked evidence of the initiation of a pain treatment plan. iii. Medical Record #19 lacked evidence of pharmacological or non-pharmacological interventions initiated for pain. iv. Medical Record #19 lacked evidence of a reassessment for pain prior to discharge. e. The facility failed to follow its policies regarding assessment, management, and treatment of patients with complaints of pain. 2. Staff #1, Staff #2, and Staff #2 confirmed the above findings.

Based on review of medical records, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure a reasonable registration process for patients seeking treatment, unduly discouraging individuals from seeking emergency medical treatment. Findings include: Reference: Facility policy, ED Triage and Trauma Triage Protocol, states, ..." II. Protocol: A. Registration of Emergency Department Patients... 3. Patients shall be triaged prior to full registration and procurement of information regarding ability to pay..." 1. Upon interview with Staff #17 on 1/4/17, it was determined that OB Triage patients are not registered in OB Triage. Triage occurs prior to arrival to the floor. 2. Upon interview with Staff #4 and Staff #6, it was confirmed that patients who arrive at the ED are registered prior to being triaged in OB triage. 3. Review of Medical Record #1, #16, and #17 revealed the following: a. Patient #1, #16, and #17 were registered prior to triage in OB triage. 4. This is a possible deterrent to individuals seeking treatment, unduly discouraging patients from coming to the Labor and the Delivery ED for evaluation/treatment. 5. The above findings were confirmed with Staff #1.