Based on review of medical records, review of facility policy and procedure and staff interview, it was determined that the facility failed to ensure the transfer form is completed in its entirety for all patients transferred out of the Emergency Department (ED). Findings include: Reference: Facility policy titled "New Jersey Universal Transfer Form Guidelines" states, "...Procedure: 1. Prior to transfer to another licensed New Jersey healthcare facility or discharge to home with home health services, the RN, Care Manager and/or other licensed healthcare provider will complete fields #1-29 on the NJ UTF {New Jersey Universal Transfer Form}..." 1. Review of Medical Record #16 on 9/24/18 revealed the following: a. The patient arrived to the ED on 8/21/18 at 2053 (8:53 PM) with a right groin second degree burn. b. The patient was transferred to a burn specialist/facility on 8/22/18 at 0307 (3:07 AM). The Universal Transfer form "Mode of Transport" section was not completed in its entirety. (i) There was no documentation of the accepting facility transport team or the name of the transport service from the sending facility in the medical record or on the transfer form. 2. Upon interview, Staff #4 stated that the receiving facility provides the transportation for the burn facility, however, it was not documented.

Based on a review of the on-call physician lists for services provided at the hospital for July, August, and September 2018 and interview with administrative staff, it was determined that some lists were incomplete, some were incorrect, and some did not include individual physician names. Findings include: 1. The "St. Joseph's Health (Paterson) ON-CALL OPHTHALMOLOGY ON CALL LIST FOR 2018" did not include the name of an on-call physician for January 1. 2. The "ST. JOSEPH'S UNIVERSITY MEDICAL CENTER DEPARTMENT OF ORTHOPAEDIC SURGERY ON-CALL HAND SCHEDULE FOR THE MONTH OF JULY 2018" did not include individual physician names for July 20, 21, 22, 24, and 31. 3. The "SOC Telemed (Neuro Call)" on-call list for September 2018 did not include the names of individual on-call physicians. 4. Administrator #4 agreed with the findings.

Based on a review of the emergency department (ED) central log, medical record reviews, and interview with administrative staff, it was determined that the facility failed to maintain a central log on each individual who comes to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged . Findings include: 1. Review of the emergency department central log indicated that Patient #4 (MDS) dated [DATE] at 12:04 PM and the disposition was documented as having occurred at 12:06 AM on 8/9/18 - 11 hours and 58 minutes after arrival. The disposition section of the log entry stated: "Left After Triage." The "ED Note Physician" section of the medical contained the entry documented as having been made at 3:39 PM on 8/8/18: "Patient seen and examined. No condition identified that requires immediate treatment. Patient is stable to continue to wait. Charge nurse notified. Patient is also aware and agreeable to the plan." The note contradicts the disposition of "Left After Triage." 2. Administrator #4 agreed with the findings.

A. Based on medical record review, review of facility policies and procedures and staff interview, it was determined that the facility failed to ensure all Emergency Department (ED) patients receive an appropriate medical screening exam (MSE). Findings include: Reference #1: Facility policy titled "Medical Screening Exam" states, " ... Medical Screening Exam. The initial and ongoing, evaluation of the presenting patient conducted by a physician/advanced practice nurse/physician assistant/emergency medicine resident ... This evaluation includes a chief complaint history and physical, appropriate diagnostic testing, completion of documentation. ..." Reference #2: The "Procedure" section of the policy and procedure titled CHEST PAIN PROTOCOL states: "1. The meeter / greeter or nurse overhead pages the ED PCA (Patient Care Associate) to triage and asks the patient to enter the ED triage area. The meeter / greeter also notifies the nurse of the patient's arrival with a chief complaint of chest pain over the age of 35. 2. Patients arriving by ambulance are expedited by the ED charge nurse. 3. The PCA completes the EKG (electrocardiogram) and presents the EKG to the physician for review and interpretation. 4. The ED physician interprets the EKG, documents the interpretation in the medical record. 5. The ED physician then completes a targeted history and physical exam. ....." 1. Review of Medical Record #3 revealed the following: a. The patient arrived to the ED on 8/4/18 at 2036 (8:36 PM) with the chief complaint, " I am almost 6 weeks pregnant and I started bleeding today." A pain assessment of three (3) out of ten (10) on the numeric pain scale was documented. b. The patient was triaged at 2052 (8:52 PM) and assigned an Emergency Severity Index (ESI) level of three (3). c. The "ED Called to Triage" was entered on 8/5/18 at 0237 (2:37 AM) and stated, "... ED Called to Triage Times Three-No answer ... ." This was six (6) hours and one (1) minute after arriving to the ED. d. The "ED Disposition Documentation" was entered on 8/5/18 at 0238 (2:38 AM) and stated, "... Patient Left Department: Left without treatment ED Reason for Leaving: Unknown ..." (i) There was no evidence that Patient #3 received a MSE. e. The above finding was confirmed by Staff #4. 2. Review of Medical Record #4 revealed the following: a. The patient was documented to have arrived at the ED and was triaged at 12:04 PM on 8/8/18. The "ED Triage Part 1 - Adult - Text" section stated: "ED Pivot - Adult Chief Complaint: having trouble breathing, his/her whole body is cramping. [Sic] woke up with a cold sweat ..... Tracking Acuity: 2 ..... Pain Assessment Adult FACES Pain Scale: 8 = Hurts whole lot ....." b. The "ED Note Physician" section contained the entry documented as having been made at 3:39 PM on 8/8/18: "Patient seen and examined. No condition identified that requires immediate treatment. Patient is stable to continue to wait. Charge nurse notified. Patient is also aware and agreeable to the plan." There were no other physician notes. c. The "Called to Triage" section stated that the patient was called back to triage from the waiting room at "2228" (10:28 PM) on 8/8/18 - 10 hours and 24 minutes after arrival. d. The "Discharge" subsection of the EVENT INFORMATION section indicated that the patient disposition from the ED was at "00:06" (12:06 AM) on 8/9/18. e. Although a physician note stated that the patient was "seen and examined," there was no documentation of the extent of the examination or specific findings. The physician did not give any orders. 3. Review of Medical Record #10 revealed the following: a. The patient was documented to have arrived at the ED on 8/8/18 at 8:11 PM. Triage was documented to have been performed at 8:18 PM. The Triage section stated: "ED Pivot - Adult Chief Complaint: chest pain and palpitations since this morning." The patient's level of pain was documented as 9 (on a pain scale of 1-10). An ESI Triage Classification of 2 was assigned. b. An EKG order was entered and completed by nursing staff, per protocol. c. The patient was documented to have left the ED 6 hours and 14 minutes after arrival. d. There was no documentation that the patient received a MSE. 4. Review of Medical Record #5 revealed the following: a. The patient arrived at the ED (Emergency Department) on 8/4/18 at 1845 (6:45 PM) with the chief complaint of head and neck pain. The pain was rated seven (7) out of ten (10) on the numeric pain scale. b. The patient was triaged at 1909 (7:09 PM) and assigned an ESI level of two (2). c. It was noted that one "Called to Triage" was entered on 8/5/18 at 0335 (3:35 AM), eight (8) hours and 50 (fifty) minutes after arriving to the ED. d. The "ED Disposition Documentation" was entered on 8/5/18 at 0335 (3:35 AM) and stated, "... Patient Left Department: Left without treatment ED Reason for Leaving: Unknown ..." e. There was no evidence that the patient received a MSE. B. Based on review of medical records, review of facility policy and procedure and staff interviews, it was determined that the facility failed to ensure that all Emergency Department (ED) patients are triaged appropriately upon arrival to the Labor and Delivery (L&D) unit. Findings include: Reference: Facility policy titled "Triage of Obstetrical Patients" states, "... Procedure: 1. Upon arrival on the unit, the triage nurse, the charge nurse or her designee will perform a brief interview and assessment of the patient to determine the patient's chief complaint ... ." 1. Review of Medical Record #12 on 9/24/18 revealed the following: a. The patient arrived to the L&D unit on 8/1/18 at 2017 (8:17 PM) with complaints of contractions and vaginal pressure. b. There was no evidence that the patient was triaged upon arrival to the L&D unit. The "Progress Notes ...OB Triage" was timed 2330 (11:30 PM). 2. Review of Medical Record #13 revealed the following: a. The patient arrived to the L&D unit on 8/1/18 at 1837 (6:37 PM) with the complaint, "I have no appetite. I feel tired." b. The "Admission H&P/Triage ... Chief Complaints" at 2001 (8:01 PM) states, "chills, headache." There was no evidence that the patient was triaged upon arrival to the L&D unit. 3. Upon interview, Staff #18 stated that triage is to be completed upon arrival to the L&D unit. 4. The above findings were confirmed by Staff #4, Staff #18 and Staff #19.

A. 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 emergency department protocol. Findings include: Reference #1: The "Procedure" section of policy and procedure titled CHEST PAIN PROTOCOL states: "1. The meeter / greeter or nurse overhead pages the ED PCA (Patient Care Associate) to triage and asks the patient to enter the ED triage area. The meeter / greeter also notifies the nurse of the patient's arrival with a chief complaint of chest pain over the age of 35. 2. Patients arriving by ambulance are expedited by the ED charge nurse. 3. The PCA completes the EKG (electrocardiogram) and presents the EKG to the physician for review and interpretation. 4. The ED physician interprets the EKG, documents the interpretation in the medical record. 5. The ED physician then completes a targeted history and physical exam. ....." Reference #2: The "Procedure" section of policy and procedure titled "Triage Protocol" states: "..... ADULT MEDICATION PROTOCOL Tylenol 650mg po (by mouth) once for a pain score > (greater than) 7 (on a scale of 1-10). If patient states a Tylenol allergy, refer to physician for additional medication order. LABS: Lactic Acid EKG: for any patient (greater than or equal to) [AGE] with complaints of pain from chin to groin ....." 1. Review of Medical Record #6 revealed the following: a. The patient arrived to the ED on 8/4/18 at 1457 (2:57 PM) with complaints of palpitations and chest pain. A pain assessment of seven (7) out of ten (10) on the numeric pain scale was documented. b. The patient was triaged at 1501 (3:01 PM) and was assigned a Emergency Severity Index (ESI) level of 2. c. An electrocardiogram (EKG) was ordered at 1501 (3:01 PM) and completed at 1512 (3:12 PM). d. The "Emergency Documentation" at 1852 (6:52 PM) stated, "Medical screening performed. [He/she] presents w/ CP [chest pain]. Pt [patient] has history of CAD [coronary artery disease] w/ [with] stents placed. Pt's EKG shows no acute ST-T changes." e. The EKG for the patient was initialed, however, there was no time noted. f. Upon interview, Staff #14 stated that the physician practice is to review the EKG findings within five (5) to ten (10) minutes of completion, and then initial and time the EKG document. g. There was no other supportive documentation addressing that the EKG findings were reviewed prior to 1852 (6:52 PM). h. The above findings were confirmed by Staff #4 and Staff #14. 2. Review of Medical Record #10 revealed the following: a. The patient (MDS) dated [DATE] at 20:11 (8:11 PM) with a chief complaint of "chest pain and palpitations since this morning." The patient's pain level in triage was documented as a "9" on the numeric pain scale. b. An ED registered nurse (RN) entered an order for an electrocardiogram as part of the CHEST PAIN PROTOCOL on 8/8/18 at 20:13 (8:13 PM). The printed EKG findings stated: "Sinus tachycardia Possible Left atrial enlargement Cannot rule out Anterior infarct, age undeterminate [sic] ABNORMAL EKG ....." c. There was no documentation that the patient received a MSE (medical screening examination). The EKG order was signed by the Chief of Emergency Medicine at 19:41 (7:41 PM) on 8/9/18. (i) There was no documentation that a PCA presented the EKG to a physician, or attempted to present the EKG to a physician, for review and interpretation. (ii) There was no documentation that an ED physician interpreted the EKG or documented the interpretation in the medical record. (iii) There was no documentation that an ED physician completed a targeted history and physical exam. There was no evidence that any history and physical was done. (iv) The RN did not enter an order for a lactic acid level nor did he/she enter an order, and administer Tylenol, as per protocol. The patient was not documented as having been allergic to Tylenol. 3. Review of the medical record of Patient #11 (same patient as Patient #10; different presenting date) revealed the following: a. The patient (MDS) dated [DATE] at 20:11 (8:11 PM) with a chief complaint, "I have high blood pressure checked it earlier it was 170 earlier." b. An ED RN entered an order for an electrocardiogram on 8/8/18 at 00:04 (12:04 AM). The printed EKG findings stated: "Normal sinus rhythm Normal EKG ....." c. There was no documentation that the patient received a history and physical examination. (i) There was no documentation that a PCA presented the EKG to a physician, or attempted to present the EKG to a physician, for review and interpretation. (ii) There was no documentation that an ED physician interpreted the EKG or documented the interpretation in the medical record. (iii) There was no documentation that an ED physician completed a targeted history and physical exam. There was no evidence that any history and physical was done. B. 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: Facility policy titled "Pain Assessment and Reassessment" states, "... All reports of pain by the patient/family/caregiver will be assessed and addressed appropriately. Pain will be treated pursuant to physician/LIP orders and/or approved alternative/complimentary therapies ... The RN will assess the patient's level of pain during the initial assessment and, thereafter, a minimum of every 4 hours, or more often pursuant to specialty area guidelines." 1. Review of Medical Record #7 indicated the patient arrived at the ED on 8/4/18 at 1303 (1:03 PM) with a complaint of right lower leg swelling. a. The patient's pain level was assessed at six (6) out of ten (10) on the facility's numeric pain scale. b. The medical record lacked evidence of the initiation of a pain treatment plan. c. The medical record lacked evidence of the use of non-pharmacological interventions to manage the patient's pain. 2. Review of Medical Record #14 indicated the patient arrived at the ED on 9/4/18 at 1740 (5:40 PM) with complaints of pain in the groin. a. On 9/4/18 at 1743 (5:43 PM), the patient's pain was assessed a six (6) out of ten (10) on the facility's numeric pain scale. b. The medical record lacked evidence that the patient was reassessed a minimum of every 4 hours after the initial complaint of pain. c. On 9/4/18 at 2201 (10:01 PM), acetaminophen 975mg stat [immediately] and lidocaine topical, 1 (one) patch now, was ordered. d. The 'Disposition Documentation' entered on 9/5/18 at 0007 (12:07 AM) states, "... pt seen by MD but eloped before RN intervention." e. The facility failed to follow its policies regarding assessment, management, and treatment of patients with complaints of pain. 3. The above findings were confirmed by Staff #4.

Based on observation and staff interview, it was determined that the facility failed to conspicuously post signage specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment of emergency medical conditions and women in labor or information indicating whether or not the hospital participates in the Medicaid program. Findings include: 1. A tour of the Emergency Department (ED) conducted on 10/19/17 at 1004, revealed that there were no EMTALA signs posted in the following areas: a. Hospital Main Entrance/Lobby b. ED Pediatric Waiting Area c. ED Family Room d. Internal Waiting Rooms #1-#3 e. (Observation Unit) ACC 5 Bay 53 f. Labor & Delivery (L&D) Triage Rooms #1-#4 2. Observation of Adult ED waiting area, revealed one (1) sign was posted in an area that was not visible where all patients are seated. 3. Observation of Internal Triage Room #3 revealed an EMTALA sign obstructed by a tall cabinet. The sign was not conspicuously posted, making visualization difficult. 4. The above findings were confirmed by Staff #3, Staff #4 and Staff #15.

Based on review of Emergency Department (ED) on-call lists and staff interviews, it was determined that the facility failed to ensure that a physician on call list, that identifies the name of an individual physician on call for a specialty, is maintained. Findings include: 1. On 10/23/17, review of the Orthopedic Surgery on-call schedule for October 2017 indicated the following: a. The name of a physician group and not an individual physician was listed as on call for the following dates: 10/3/17, 10/4/17, 10/5/17, 10/6/17, 10/7/17, 10/8/17, 10/9/17, 10/10/17, 10/12/17, 10/17/17, 10/18/17, 10/19/17, 10/20/17, 10/21/17, 10/22/17, 10/23/17, 10/24/17, 10/25/17, 10/26/17, 10/27/17, 10/28/17, 10/29/17, and 10/30/17. 2. On 10/23/17, review of the Pediatric Physician on-call schedule for May 2017 indicated the following: a. From May 1, 2017 to May 31, 2017, under the name of the physician on-call for adols (adolescents) it states, "see attached sheet." b. There was no evidence of an additional sheet listing the name(s) of the physician on-call for adolescents during the month of May, 2017. 3. Staff #1 and Staff #27 confirmed the above findings.

Based on review of medical records, staff interviews, and review of facility documents, it was determined that the facility failed to ensure all Emergency Department (ED) patients received an appropriate medical screening exam (MSE), which includes appropriate classification from the triage nurse based on the Emergency Severity Index (ESI). Findings include: Reference #1: Facility policy Triage Protocol states, "... Patient triage determines the order in which the patient is medically screened by the ED physician. ... Procedure: ... 3. When ED beds are not available, the Triage Nurse(s) assess patients, assign acuity levels, and provide minor first aid as needed. Acuity levels are based on the Emergency Severity Index (ESI) 5 level triage tool that uses resources and acuity to categorize patients. ... ." Reference #2: Emergency Severity Index (ESI) Algorithm states, "... B. ... Severe pain/distress is determined by clinical observation and/or patient rating of greater than or equal to 7 on 0-10 pain scale. ... Box B: Severe pain/distress? - ESI level rating 2 ... Box D: Danger zone vitals? ... 3-8y/ HR >140/ RR >30/ SaO2 <92% - ESI level rating 2 ... ." 1. Review of Medical Record #1 on 10/21/17 indicated the following: a. The patient arrived to the ED on 6/19/16 at 1955 with complaints of abdominal pain rated nine (9) out of ten (10) on the numeric pain scale. The patient stated she had a Caesarean section a couple of weeks prior to arriving at the ED. b. The patient was triaged at 2004 and assigned an ESI level of three (3). The ESI triage algorithm indicated an ESI level of two (2) is assigned for severe pain greater than seven (7) on the numeric pain scale. c. The patient was first called to come into the treatment area on 6/20/17 at 0123, five (5) hours and twenty-eight (28) minutes after arriving to the ED. d. ED documentation indicated the patient left without treatment (LWT) on 6/20/17 at 0248. There was no evidence that the patient received a medical screening exam (MSE). 2. Review of Medical Record #2 on 10/21/17 indicated the following: a. The patient arrived to the ED on 6/19/16 at 2107 with complaints of pain to his/her nose and right arm, eight (8) out of ten (10) on the numeric pain scale. The patient stated he/she fell down steps and hit his/her face on the concrete steps. b. The patient was triaged at 2148 and assigned an ESI level of three (3). The ESI triage algorithm indicated an ESI level of two (2) is assigned for severe pain greater than seven (7) on the numeric pain scale. c. The patient was first called to come into the treatment area on 6/20/17 at 0421, seven (7) hours and fourteen (14) minutes after arriving to the ED. d. ED documentation indicated the patient LWT on 6/20/17 at 0456. There was no evidence the patient received a MSE. 3. Review of Medical Record #3 on 10/21/17 indicated the following: a. The patient arrived to the ED on 6/19/16 at 2205 with complaints of a headache rated seven (7) out of ten (10) on the numeric pain scale. The patient stated his/her carbon monoxide monitor went off and the fire department found carbon monoxide present in the home. b. The patient was triaged at 2252 and assigned an ESI level of three (3). The ESI algorithm indicated an ESI level of two (2) is assigned for severe pain greater than seven (7) on the numeric pain scale. c. On 6/20/16 at 0036, the patient was called to the treatment area for the first time. The patient did not respond. d. On 6/20/16 at 0042, the patient states he/she is going to leave and come back in the morning because of the wait time. e. ED documentation indicated the patient LWT on 6/20/16 at 0127. There was no evidence the patient received a MSE. 4. Review of Medical Record #7 on 10/20/17 revealed the following: a. Patient #7 arrived at the ED on 5/16/17 with complaints of fever and vomiting and was assigned an ESI level 5. b. Patient #7 falls within the age range of 3-8 years of age. c. Triage vital signs indicated Pulse 144, Resp 20, Temp 100.2 (TE). d. According to the facility's ESI algorithm, the appropriate ESI level was 2. 5. Review of Medical Record #16 on 10/20/17 revealed the following: a. Patient #16 arrived at the ED on 5/31/17 with complaints of vaginal pain, abscess and was seventeen (17) weeks pregnant. b. Triage was completed at 2108. There was no documented evidence of a pain assessment upon triage. The patient was assigned an ESI level 3. c. At 2249, Patient #16 rates her pain level 7 out of 10 in buttocks and abdomen. d. According to the facility's ESI algorithm, severe pain (pain greater than or equal to 7) required an ESI 2 classification. 6. Staff #1, Staff #20 and Staff #27 confirmed the above findings. 7. The medical record of Patient #13 indicated that the patient's chief complaint in triage included vaginal itching and pain. There was no pain level assigned to the patient by the triage nurse. The patient was assigned an ESI 3 classification. Since there was no pain scale for the patient, it could not be determined whether the patient should have been classified as ESI 2. 8. The medical record of Patient #17 indicated that the patient's pain level during triage was "10" on a scale of 1-10. The patient was assigned an ESI level 3. According to the facility's ESI algorithm, severe pain (pain greater than or equal to 7) required an ESI 2 classification. 9. The medical record of Patient #18 indicated that the patient's pain level during triage was "10" on a scale of 1-10. The patient was assigned an ESI level 3. According to the facility's ESI algorithm, severe pain (pain greater than or equal to 7) required an ESI 2 classification. 10. The medical record of Patient #25 indicated that the patient was brought to the ED on 10/19/17 by ambulance accompanied by police. The triage nurse documented: "Presenting complaint: Patient states: He took a handful of Buproprion pills because his girlfriend broke up with him [sic] EMS states: Patient took a bunch of pills to try to kill himself. ....." The patient was assigned a triage classification of ESI 3. According to the facility's ESI algorithm, the patient was in a high risk situation and should have been classified as an ESI 2.

Based on review of medical records, staff interviews, and review of facility policies and procedures, it was determined that the facility failed to provide stabilizing treatment, within the capabilities of the facility, for all patients who present to the Emergency Department (ED). Findings include: Reference #1: Facility policy "Triage Protocol" states, "... 4. A Pivot Nurse is assigned to the waiting area to support the triage process and provide ongoing reassessments of patients pending bed assignments in the ED. 5. The Triage nurse or other on-duty nurses may initiate... initial medications based on protocol to expedite patient care. ... Adult Medication Protocol: Tylenol 650 mg po (by mouth) once for temp (temperature) greater than 101 F or complaints of pain or Motrin 600 mg po once for temp greater than 101 F or complaints of pain." Reference #2: Facility policy "Pain Assessment and Reassessment" states, "... Pain management is accomplished through assessment, administration of appropriate treatment, and reassessment/evaluation of treatment. ... Pain Assessment and Reassessment... Emergency Department: The RN will assess the patient's level of pain during the initial assessment, and, thereafter, a minimum of every 4 hours, or more often pursuant to specialty area guidelines... ." Reference #3: Facility policy titled "Constant Observation for the Suicidal Patient" stated: "..... PURPOSE: Identifies personnel responsibilities during the constant observation of a suicidal patient, thereby protecting the patient from potential harm and elopement until a Physician/Psychiatric screening/consult evaluation has been completed and the need for continued observation established. POLICY: Patients deemed to be at high risk for suicidal behavior(s) and/or elopement are placed on constant observation until a physician/psychiatric screening/psychiatric consult has been completed and the need to continue the observation is established. 1. The Registered Nurse facilitates the physician and psychiatric screening/consult of the patient. 2. A Registered Nurse, PCA, Psychiatric Screener, Security Officer, Transport Personnel, may provide the constant observation. ..... PROCEDURE: 1. Constant observation may be initiated by the registered nurse. 2. The patient's room is inspected for items and environmental hazards which can be used to inflict self harm, documentation in the medical record reflects their removal. 3. The patient is changed into a hospital gown, clothing is removed including undergarments. Clothing and valuables are then removed from the room and secured in an area not accessible to the patient. ..... 5. The observer remains with the patient at all times. The patient is escorted to the bathroom and diagnostic area(s) by the observer. The observer is relieved by another employee for breaks/meals, etc. ..... 8. Constant observation is discontinued with the following circumstances: - patient agrees to voluntary admission - patient is no longer suicidal - patient is to be discharged - Time of transfer to another facility - An order is received from a LIP (Licensed Independent Practitioner) discontinuing the constant observation. ....." 1. Review of Medical Record #1 on 10/21/17 indicated the following: a. The patient arrived to the ED on 6/19/16 at 1955 with complaints of abdominal pain rated nine (9) out of ten (10) on the numeric pain scale. The patient indicated she had a Caesarean section a couple of weeks prior to arriving to the ED. b. ED documentation indicated the patient left without treatment (LWT) on 6/20/16 at 0248. c. There was no evidence in the medical record that Tylenol or Motrin were initiated for pain management during the patient's wait in the ED, as indicated in the triage policy. d. There was no evidence in the medical record that the patient's pain was reassessed after four (4) hours. 2. Review of Medical Record #2 on 10/21/17 indicated the following: a. The patient arrived to the ED on 6/19/16 at 2107 PM with complaints to his/her nose and right arm rated eight (8) out of ten (10) on the numeric pain scale. The patient indicated he/she fell down steps and hit his/her face on concrete steps. b. ED documentation indicated that the patient LWT on 6/20/16 at 0421. c. There was no evidence in the medical record that Tylenol or Motrin were initiated for pain management during the patient's wait in the ED, as indicated in the triage policy. d. There was no evidence in the medical record that the patient's pain was reassessed after four (4) hours. 3. Review of Medical Record #3 on 10/21/17 indicated the following: a. The patient arrived to the ED on 6/19/16 at 2205 with complaints of a headache rated seven (7) out of ten (10) on the numeric pain scale. The patient indicated the carbon monoxide detector went off in his/her home, and the fire department detected elevated CO2 levels in the home. b. ED documentation indicated that the patient LWT on 6/20/16 at 0127. c. There was no evidence in the medical record that Tylenol or Motrin were initiated for pain management during the patient's wait in the ED, as indicated in the triage policy. 4. Review of Medical Record #16 on 10/20/17 revealed the following: a. Patient #16 arrived at the ED on 5/31/17 with complaints of vaginal pain, abscess and is seventeen (17) weeks pregnant. b. Triage was completed at 2108. c. At 2249, Patient #16 rates pain level 7 out of 10 in buttocks and abdomen. d. The initial triage assessment lacked evidence of a pain assessment. 5. Review of Medical Record #20 on 10/20/17 revealed the following: a. Patient #20 arrived at the ED on 7/1/17 at 1446 with complaints of back and chest pain. b. Triage was completed at 1452. c. At 1503, Patient #20 rates pain level 9 out of 10 in left clavicle, anterior aspect of left upper chest and mid sternal area. d. The initial triage assessment lacked evidence of a pain assessment. 6. Staff #1, Staff #20 and Staff #27 confirmed the above findings. 7. Review of the medical record of Patient #8 revealed: a. The patient was brought to the ED by ambulance and arrived at 1136 on 5/16/17. The triage nurse documented that the patient was found on a strangers steps in a different town. He/she also documented that the patient smelled of alcohol and had a seizure. The patient was assigned an ESI Acuity Level 1. b. The medical record documented that the Medical Screening Exam was completed at 1128. The ROS (Review of Systems) section of physician documentation stated: "..... Psych: Positive for suicidal ideation, hallucinations. ....." The HPI (History of Present Illness) section of physician documentation stated: "..... Patient reports he drinks alcohol daily and he drank a lot yesterday. Patient also reports he is experiencing suicidal ideation and hallucinations. ....." c. The patients blood was drawn for a blood alcohol concentration and it was determined to be 406. (i) The patient was not placed on constant observation status by either the registered nurse or the physician. (ii) The patient was placed on a stretcher in the hallway instead of in a room with an observer. (iii) A psychiatric consult or screening was neither ordered or done. (iv) The patient was documented as having eloped from the ED with a saline lock still inserted.

Based on medical record review, review of facility policy and procedure, and staff interviews, it was determined that the facility failed to ensure a transfer form is completed for all patients transferred out of the Emergency Department (ED). Findings include: Reference: Facility policy BH (Behavioral Health) - Transfer of Patients to Other Institutions from [Facility Name] states, "... Procedure ... 3. A transfer form is to be completed. The ER physician will complete the physician's portion; the nurse will complete the portion relevant to nursing; ... The name of the receiving physician accepting the transferred patient will appear on the form as well. 4. The original is kept in the ED record and a copy is sent with the patient to the receiving hospital. ... ." 1. Review of Medical Record #19 on 10/20/17 indicated the following: a. The patient (MDS) dated [DATE] at 12:58 PM with complaints of suicidal ideation. The triage assessment indicated the patient's child stated the patient was "acting strange" and needed a psychiatric evaluation. b. On 7/1/17 at 2:16 PM, the patient received a psychiatric assessment by the Psychiatric Social Worker, with a recommendation to admit the patient to an inpatient psychiatric facility. c. The patient was transferred to an inpatient psychiatric facility on 7/2/17 at 2:33 AM. There was no evidence of a transfer form in the patient's medical record. d. Upon interview, Staff #20 indicated that a transfer form for Patient #19 was not necessary because he/she was a committed patient. 2. Staff #1 and Staff #27 confirmed the above findings.