Based on a review of the medical records of 37 patients, interviews with administrative staff, tours of the emergency departments of three campuses, a review of hospital policies and procedures, and a review of related documentation, it was determined that the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice. Findings include: 1. The facility failed to ensure that emergency services were integrated with other departments of the hospital. (Refer to Tag A 1103) 2. The facility failed to ensure that policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. (Refer to Tag A 1104)

Stratford A. Based on a tour of the emergency department at the Stratford Campus, review of hospital policy and procedure, review of a contract, and interview with administrative staff, it was determined that emergency services are not integrated with other departments of the hospital. Findings include: Reference #1: Central Processing Department policy and procedure titled, "Preventative Maintenance of CPD (Central Processing Department) Equipment" states: "PURPOSE: To define a procedure to insure that preventative maintenance of CPD equipment is performed. RESPONSIBILITIES: It is the responsibility of the CPD Assistant Manager/Supervisor and the BioMed technician to check the dates on the inspection sticker and take corrective action as needed. The Bio-Medical Department representative is responsible for performing the required service inspections as outlined below. The CPD Assistant Manager/Supervisor is responsible for the enforcement of this policy. ..... POLICY: The Bio-medical Department shall be responsible to provide necessary inspections of Central Processing Department (CPD) equipment to verify accurate functioning and service performance. PROCEDURE: 1. CPD electronic medical device service and preventative maintenance is overseen by Biomedical Engineering. ..... b. In order to insure that all medical electronic CPD devices are safe for use: i. The user verifies that the devices have a valid safety inspection sticker and [sic] ii. The user performs an operational check prior to use ... 3. Required inspection of services shall be made: [sic] ..... 7. Scheduled/Routine inspection. 8. Process of notification for inspection and services as follows: [sic] 9. CPD shall notify the Bio-Medical Department (via the HELPDESK) of the need for inspection and services for applicable equipment. 10. The Bio-Medical Department shall be responsible to provide a program for scheduled/routine inspection and services at criteria-based maintenance intervals in accordance with the Joint Commission and NJDOH (New Jersey Department of Health) standards. 11. If equipment is under a preventative maintenance contract with the O.E.M. (original equipment manufacturer) Bio-Medical will notify the O.E.M. for needed repairs and service. The O.E.M. will be responsible for adhering to the preventative maintenance agreement scheduled. 12. Maintenance of records for inspection and services: [sic] 13. CPD and Bio-Medical Departments shall identify all equipment by nomenclature, model number, part number, manufacturer, and the history of services. 14. An 'Inspection Tag' shall be affixed, [sic] by the Bio-Medical Department representative upon completion of said inspection with date, identification of person performing inspection and department. 15. The Inspection tag shall not be removed by anyone other than a representative of the Bio-Medical Department." Reference #2: A contract titled "ONE YEAR AGREEMENT BETWEEN MAJOR MEDICAL HOSPITAL SERVICES, INC AND Jefferson Memorial Hospital Systems" states that 151 Continuous Suction Regulators and 122 Intermittent/Continuous Suction Regulators at the Stratford Campus would have annual inspection, cleaning, and inventorying. The contract was dated March 1, 2018. 1. A tour of the 'Ready Room' of the Stratford Campus Emergency Department on 11/27/18 revealed: a. A locked cabinet in Bay #3 contained a suction regulator with a tag indicating that it was calibrated in "4/15" (April 2015) and was due for calibration in "4/16" (April 2016); and a suction regulator with a tag indicating that it was calibrated in "3/17" (March 2017) and was due for calibration in "3/18" (March 2018). b. A locked cabinet in Bay# 4 contained a suction regulator with a tag indicating that it was calibrated in "4/15" (April 2015) and was due for calibration in "4/16" (April 2016). 2. Administrator #19 agreed with the findings. Washington Township B. Based on medical record review and staff interview, it was determined that the facility failed to ensure that there is coordination and communication between the Emergency Department (ED) and the contracted provider for Crisis and emergency intervention services on the Washington Township Campus. Findings include: 1. During an interview on 11/27/18 at 10:45 AM, Staff #WA4 stated that emergency room patients who require a crisis screening would be seen by a screener from (name of crisis/behavioral health facility). a. At 11:00 AM, Staff #WA10 stated that the crisis screeners do not chart their findings in the medical record and do not give a written report after speaking with a ED patient that is in crisis. (i) Staff #WA10 and Staff #WA17 stated that the ED staff will have a discussion with the (name of crisis/behavioral health facility) crisis screener regarding the patient's condition but that the discussion or the crisis screeners findings are not always documented in the medical record. 2. A review of Medical Record #WA6 contained a physician's order, dated 8/24/18, that stated "Medically Cleared for Crisis Screener." a. Medical Record #WA6 contained a Psychiatric Emergency Screening Center Center - (name of county) Outreach Request Form, requesting a crisis screener see Patient #WA6 for Suicidal ideation's. (i) There was no evidence that the crisis screener evaluated Patient #WA6 as requested by the physician. 3. A review of Medical Record #WA7 contained evidence that the patient was referred to Crisis for screening related to suicidal ideation on 7/4/18 at 9:43 PM. a. A nursing note dated 7/5/18 at 12:19 PM states, "Crisis at bedside to eval [evaluate] pt. [patient]." b. Documented evidence in a discharge note dated 7/5/18 at 3:12 PM states that the patient was discharged home at this time. (i) The medical record lacks evidence that the patient was cleared for discharge by the Crisis screener performing the evaluation. c. The above finding was confirmed with Staff #WA13 on 11/28/18. Cherry Hill C. Based on document review, staff interviews, and observation, it was determined that the facility failed to integrate and coordinate services provided by other departments of the hospital. Findings include: Reference #1: Policy titled "Admission to Behavioral Health Inpatient Services" states, "... Procedure ... 1. Referrals may be taken by a Registered Nurse (RN), Master's Level Clinician (MLC) or Social Worker (SW) ..... 4. Referrals may not be rejected by anyone other than: The Attending Physician/Psychiatric Resident, Nurse Manager, or Clinical/Corporate Director for Behavioral Health Services in consultation with the Attending Psychiatrist/Psychiatric Resident when medical/clinical issues arise, or, The Nurse Manager, Corporate/Clinical Director for Behavioral Health services or designee when operational or service related issues arise ... ." Reference #2: Policy titled "Admission Criteria Adult Inpatient Mental Health Unit (West Pavilion)" states, "...Policy ... Voluntary Admissions: Individuals must meet the following criteria in order to be admitted to the West Pavilion: 1. A mental disorder (DSM 5 in definition) is present..... 5. One or more of the following are present: ... c. Persistent suicide ideation ..... f. Bizarre behavior, agitation, ... depression ... ." 1. On 11/28/18, the medical record of Patient #CH1 (Cherry Hill) was reviewed. Patient #CH1 presented to the facility emergency department (ED) on 5/24/18 for an evaluation of depression with suicidal ideation. Staff #CH7, an ED nurse, performed a safety assessment at 11:11 AM, and assessed Patient #CH1 with a suicide risk level 1 and suicide precautions were initiated. a. On 5/24/18 at 11:49 AM, it was noted by Staff #CH29, an ED physician, that the patient stated he/she had a plan, wrote a letter, and had wanted to end his/her life overnight. (i) Staff #CH29 noted at 11:49 AM that Patient #CH1 appeared agitated and anxious. (ii) Staff #CH29 also indicated that the patient's symptoms were worsening, were constant, and were associated with suicidal thoughts. 2. A physical exam was conducted at 11:54 AM by Staff #CH29 that indicated that Patient #CH1 was tachycardic, hypertensive, and appeared uncomfortable. a. Staff #CH29 indicated in the psychiatric portion of the exam that Patient #CH1 was anxious with poor judgement, and had suicidal ideation's present with a plan. 3. Staff #CH14, a master's level clinician, noted on 5/24/18 at 12:11 PM that "...pt [patient] came to the ED... because [he/she] has ongoing depression and suicidal ideations..... Pt's mood is depressed with a flat affect... Pt stated [he/she] has not received any Psychiatric Treatment since Oct [October] 2017..... Pt reports that is [sic] [he/she] would leave the hospital today [he/she] would buy 10 bags of heroin and shoot up and kill [himself/herself]..... Pt's [family member] agrees with pt's statement and stated that [he/she] does not feel pt is safe to leave the hospital at this time and knows that pt will kill [himself/herself] if [he/she] leaves the hospital. ....." a. There was a lack of documentation in the note that indicated a referral for inpatient admission. b. There was no order noted in the medical record by a physician for crisis evaluation and/or behavioral health evaluation. (i) There was a lack of documentation that the patient had been medically cleared for a crisis and/or a behavioral health evaluation. 4. Staff #CH7 assessed Patient #CH1 at 12:18 PM and noted that suicidal ideations were present. 5. Staff #CH14 noted at 1:42 PM, "...INTERVENTIONS: Consulted with ED Provider/Interdisciplinary Team, Met with patient, Met with parent/Family/Caregiver....." a. There was a lack of documentation of what interventions were provided at that time. 6. Staff #CH14 indicated in a note written at 1:42 PM that the patient was denied inpatient admission at the facility, and that the patient and family felt that the patient had stabilized and was no longer suicidal. a. It was unclear why Patient #CH1 was denied inpatient admission to the facility. (i) There was a lack of evidence of referrals made to other facilities. b. Staff #CH14 also indicated in the note that Patient #CH1 would be discharged to home-no services needed. c. It was unclear what interventions were provided, and by whom, that had stabilized Patient #CH1 during the 1 hour and 29 minutes in between the notes written by Staff #CH14. 7. Patient #CH1 was discharged on [DATE] at 1:59 PM. a. Staff #CH29 indicated in a note written at 1:52 PM, "...I expressed my concerns and explained to return to the ED at any time....." (i) There was a lack of evidence that indicated Patient #CH1 was stable for discharge home. 8. The facility was unable to provide the following evidence of the referral process pertaining to Patient #CH1 for inpatient services: a. The facility was unable to provide evidence that a psychiatrist evaluated the patient. b. The facility was unable to provide evidence of who rejected the inpatient referral. c. The facility was unable to provide evidence of the reasons why the referral was rejected. 9. Staff #CH9 confirmed the above findings. D. Based on medical record review and staff interview, it was determined that the facility failed to ensure that there is coordination and communication between the Emergency Department (ED) and the contracted provider for Crisis and emergency intervention services on the Cherry Hill Campus. Findings include: 1. During an interview with Staff #CH3, Staff#CH4, and Staff #CH8, it was stated that emergency room patients who require a crisis screening would be seen by a screener from (name of crisis/behavioral health facility). a. It was also revealed in an interview with Staff #CH3 and Staff #CH4 that a crisis screening/evaluation would be physician order driven. b. Staff #CH3 and Staff #CH8 stated that the (name of crisis/behavioral health facility) crisis screeners do not chart their findings in the medical record and do not give a written report after speaking with a ED patient that was in crisis. c. Staff #CH3 and Staff #CH8 stated that ED providers should document that the patient was screened by crisis. 2. A review of four (4) medical records (#CH4, #CH5, #CH6 and #CH7) that were evaluated by crisis revealed that the evaluation was not placed in the medical records. a. Patient #CH4 had a physician's order that indicated medically cleared for behavioral health evaluation, but it noted that the patient was seen by crisis. (i) Staff #CH30 indicated in a note written on 6/26/18 at 7:39 PM that the patient's disposition was placed per crisis recommendations. (ii) The medical record lacked documentation of the crisis recommendations. b. Patient #CH5 had a physician's order that indicated that the patient was medically cleared for a crisis screener. (i) Staff #CH31 indicated in a note that the patient's disposition was made by crisis. (ii) The medical record lacked evidence of the crisis recommendations and disposition. c. A physician order dated 5/21/18 in Medical Record #CH6 directed that the patient was "Medically cleared for Crisis Screener." (i) A note by the ED physician at 0453 on 5/21/18 stated, "Patient seen and evaluated by crisis. Disposition placed per crisis recommendations." (ii) The medical record lacked evidence of the crisis recommendations and disposition. (iii) On 11/28/18 at 2:00 PM, Staff #9 obtained and provided from the Crisis Unit staff, the crisis notes for patient #CH6's visit on 5/21/18. d. Patient #CH7 had a physician's order written on 8/15/18 at 12:47 PM that indicated that the patient was medically cleared for a crisis screener. (i) The medical record revealed a note written by Staff #CH12 on 8/15/18 at 1:15 PM of a behavioral health assessment. Staff #CH12 is not a crisis screener. (ii) There was no documented evidence in the medical record of Patient #CH7 that indicated the patient was seen by a crisis screener as requested by the physician.

Cherry Hill A. Based on medical record review, staff interview, and review of facility policy and procedure, it was determined that the facility failed to ensure patients identified as at risk for suicide, had their belongings checked for contraband in accordance with facility policy, in two (2) of three (3) medical records reviewed at the Cherry Hill campus on 11/28/18 (Medical Records #CH6 & #CH9). Findings include: Reference: Facility Policy Number S-8, titled, "Suicide Risk Assessment and Interventions for Adolescent and Adult Patients," states, "POLICY To effectively reduce the risk of suicide in the inpatient and emergency department settings; --[facility name]-- hospital identifies patients at risk of suicide and then intervenes to prevent suicide in those patients identified at risk. ... PROCEDURE: ... 3. Implement Suicide Precautions as Indicated. [bullet] Implement Suicide precautions based upon a Tiered Intervention System (Moderate Risk or High risk) for patients with active suicidal thoughts- total risk assessment screen score 2 or greater. ... Moderate Risk Suicide Interventions: ... In addition to orders given by the physician, other interventions to prevent suicide in those patients with increased risk may be implemented: 1. Inventory patient belongings 2. Check the patient for contraband ... 4. Create a safe environment. Belongings secured. ..." 1. A review of Medical Record #CH6 indicated per the triage notes dated 5/21/18 at 00:01 that the patient was sad all the time, had thoughts of hurting himself/herself, and was currently suicidal without a plan. Documentation in the Safety Assessment section of triage notes states, "Patient agrees with statement: I would like to kill myself., (sic) Risk Level: 2, ..." a. There was no evidence in the medical record of an inventory of the patient's belongings for contraband. b. On 11/28/18 at 2:20 PM, Staff #CH3 confirmed the above. Staff #CH3 stated that there was no evidence in the medical record that the patient was provided with green scrubs to change in to, and there was no evidence of a Patient Search Form. 2. A review of Medical Record #CH9 indicated per the triage notes dated 6/28/18 at 11:21, in the Safety Assessment section, that the "Patient admits thoughts to kill self, but denies willingness to act., (sic) Risk Level: 1, ... Suicide precautions initiated. ..." a. There was no evidence in the medical record of an inventory of the patient's belongings for contraband. b. On 11/28/18 at 2:30 PM, Staff #CH3 confirmed the above. Washington Township B. Based on medical record review, staff interview, facility policy review, it was determined that the facility failed to ensure that all patients receive discharge instructions upon discharge. Findings include: Reference: Facility policy, "Discharge Instructions" states, "... POLICY: Prior to discharge from the Emergency Department, each patient will receive written instructions regarding their diagnosis, treatment and follow-up care. ... PROCEDURE: [bullet} or patient representative signs the instructions indication [sic] that the patient/rep. (representative) understands treatment and follow-up care ..." 1. Medical Record #WA12 contained a Discharge Instruction Receipt, dated 4/18/18. a. The patient signature section that indicated that the patient received the discharge instructions was left blank. 2. On 11/28/18 at 1:40 PM, Staff #WA10 confirmed the above findings. Cherry Hill C. Based on staff interview, it was determined that the facility failed to ensure that there was a policy and protocol in place that addresses the roles and involvement of hospital health professionals in the care of a behavioral health patient. Findings include: 1. A tour of the Cherry Hill Emergency Department (ED) was conducted on 11/27/18 in the presence of Staff #CH3, Staff #CH4, and Staff #CH5. The following was noted: a. Interviews with Staff #CH3, Staff #CH5, and Staff #CH9 confirmed that the facility has its own behavioral health team for ED evaluations as well as a contracted crisis service for ED psychiatric evaluations. (i) Upon request, the Cherry Hill facility was unable to provide a policy or protocol that would address the individual roles of the behavioral health team and the crisis team in evaluating behavioral health patients. (ii) Staff #8 stated during interview on 11/27/18 at 11:00 AM, that the physician will enter an order for Crisis to see a patient or for Behavioral Health. Staff #8 stated the order is specified by the doctor as to who the doctor wants to evaluate the patient; Crisis or Behavioral Health. 2. Review of two (2) out of three (3) medical records (#CH2, and #CH9) at the Cherry Hill campus of patients that the ED physician ordered to be evaluated by Crisis, lacked evidence that the patients were seen by Crisis, but were evaluated by the ED's behavioral health team as follows: a. Documented evidence in the triage notes, on 4/13/18, in Medical Record #CH2 stated, "pt [patient] reports struggling with post partum depression and today feels suicidal with plan to take a bath and cut her wrists. ...". The Doctor's notes state, "... rev with pt need for medical eval. rev that ED does medical clearance and that crisis will eval for what services may be offered /needed regarsding (sic) acute emotional issue. pt ok with plan." (i) The medical record contained evidence that the patient was seen and evaluated by Staff #CH12, a Social Worker (SW) from the facility. Staff #CH12 documented that the patient could plan for safety outside the hospital, did not need inpatient psychiatric treatment as she was not a danger to herself/others at this time, and planned for the patient to attend outpatient group therapy. (ii) Staff #CH12 stated in an interview on 11/27/18 at 11:55 AM, that he/she reviews who is coming to the ED to see if he/she can see the patient instead of Crisis, because Crisis is usually very busy. He/she will see the patients that may be seeking voluntary psychiatric level of care. Staff #CH12 stated he/she is not a licensed screener so he/she cannot see involuntary type patients. b. Documented evidence in the triage notes, on 6/28/18, in Medical Record #CH9 stated, "... Patient admits thoughts to kill self, but denies willingness to act. ...". The ED physician evaluated the patient and ordered "Medically Cleared for Crisis Screener." (i) The medical record contained evidence per a digital signature by Staff #CH12, that the patient was seen and evaluated by him/her, however, the documented notes by the SW were from previous admissions on 6/20/18, and 6/12/18. There was no documented assessment of Patient #CH9 by the SW for this ED visit on 6/28/18. (ii) A disposition note by an attending ED physician stated, "Patient was seen by BH Specialist who deemed patient safe for discharge." (iii) There was no evidence in the medical record that Patient #CH9 contracted for safety prior to his/her discharge. This was confirmed by Staff #CH3 on 11/28/18 at 2:00 PM. Washington Township 3. On 11/27/18 at 11:00 AM, upon request, Staff #WA14 was unable to provide a policy and procedure that would address the individual roles of the behavioral health team and the crisis team in evaluating behavioral health patients. Washington Township D. Based on medical record review, facility policy review, review of medical staff bylaws, and staff interview, it was determined that the facility failed to ensure that policies and procedures governing emergency medical care are implemented by the medical staff. Findings include: Reference #1: Facility policy titled, "Response Obligations for Physicians Covering ED [Emergency Department] Unassigned Patients EMTALA," states, "... Any patient presenting with an emergency medical condition must receive treatment, within the capability of Kennedy, to stabilize the emergent condition. ..." Reference #2: Facility Medical Staff Bylaws state, "... 4. An emergent medical condition is defined as a life threatening condition manifesting itself by acute symptoms of severity (including pain or behavioral disorder) that could result in: a. Placing the health of the individual in serious jeopardy ..." 1. A review of Medical Record #WA8 revealed that the patient did not receive treatment for an emergency medical condition, as follows: a. The patient was triaged in the ED on 7/27/18 at 12:42 PM. (i) A triage note at this time states, "PT [patient] TEARFUL IN TRIAGE .PT [sic] REPORTS [he/she] IS "BASICALLY HOMELESS NOW", WAS LIVING WITH [his/her] UNCLE THEN GIRLFRIEND STATES [he/she] TRIED HANGING [himself/herself] YESTERDAY "I FEEL LIKE I WANT TO DIE" BECAUSE [he/she] HAS A LOT GOING ON. ..." (ii) A safety assessment, which included a suicide risk assessment, was conducted at 12:53 PM and states, "...SAFETY ASSESSMENT: Patient agrees with statement: I would kill myself if I had the chance., ... Suicide precautions initiated. ..." b. A physician performed a physical exam at 1:16 PM, which states, "... PSYCHIATRIC: ... Affect, flat, tearful, Suicidal ideations present, no plan, denies willingness to act while in the ED, Homicidal ideations present, without plan." c. An assessment by Behavioral Health at 2:48 PM states, "ASSESSMENT: Notes: Behavioral Health Nurse Case Manager: Pt. was referred for assessment after [he/she] came to the ED reporting that [he/she] attempted to hang [himself/herself], is homeless and has no where to go. ... UDS [urine drug screen] is (+) [positive] cocaine. ... will be referred to [name of substance abuse counselors]. [He/She] states that [he/she] is tired of living this way and doesn't want to go on anymore. Dual bed search initiated. Chart will be faxed to [Facility name] for review. Pt presents with blunted affect and depressed mood. Dr. [Name] informed of same." (i) The medical record lacks evidence that the patient was transferred to an inpatient facility as per the intent of the Behavioral Health Case Manager. d. A nursing assessment at 3:04 PM states, "Psychiatric/social assessment findings include affect, crying, depressed, tearful, ... Suicidal ideations present, no homicidal ideations, Notes: pt states [he/she] is depressed and suicidal, feels as though [he/she] is not 'worth it'." e. A physicians note at 3:15 PM states, "NOTES: Patient seen and evaluated by crisis, cleared for discharge home. Denies any suicidal or homicidal ideation. Given referrals." (i) The medical record lacks evidence that the patient was seen and evaluated by crisis. (ii) The medical record lacks evidence that Behavioral Health informed the physician that the patient was appropriate for discharge. (iii) This note is inconsistent with the nursing note entered 11 minutes prior which stated that the patient was suicidal. f. A discharge note from the registered nurse at 3:26 PM states, "DISCHARGE: Patient discharged to home, ambulating without assistance, transported via taxi, unaccompanied, ... Taxi voucher given to patient, Patient treated and evaluated by physician." (i) The patient being discharged to "home" is inconsistent with documentation that the patient was homeless. 2. During an interview on 11/28/18 at 1:30 PM, Staff #WA21 stated that based on Patient #WA8's attempt at suicide, he/she should have been admitted as an inpatient. Staff #WA21 stated that the meaning of a "dual bed search" was to find an inpatient placement that would treat the patient's substance abuse and depression. Staff #WA21 stated that the patient should not have been discharged while awaiting his/her chart to be reviewed by an inpatient facility. Staff #WA21 stated that he/she checked with the facility substance abuse counselors referenced above and they did not have a record of the patient. 3. The ED physician (Staff #WA25) who treated Patient #WA8 on 7/27/18 was interviewed on 11/28/18 at 2:04 PM. Staff #WA25 stated that he/she could not remember this particular patient, but based on his/her notes in the medical record, Staff #WA25 believed that the patient was going to a rehab (rehabilitation) facility and was cleared for discharge. 4. The above findings were confirmed with Staff #WA8, Staff #WA13, Staff #WA14, and Staff #WA21 on 11/28/18 at 2:00 PM. Cherry Hill E. Based on document review and staff interview, it was determined that the facility failed to ensure that policies are in place to create a safe environment for the behavioral health patient. Findings include: Reference: Facility Policy, "Suicide Risk Assessment and Interventions for Adolescent and Adult Patients," states, "... PURPOSE Suicide risk assessment aids in identifying patients that may present an imminent or actual threat of harm to themselves. Environmental safety measures are implemented to minimize risk. .... Procedure: ... Moderate Risk suicide Interventions: ... 4. Create a safe environment. ..." 1. A tour of the emergency department (ED) was conducted on 11/27/18 in the presence of Staff #CH3, Staff #CH4, and Staff #CH5. The following was noted: a. An interview with Staff #CH3 and Staff #CH4 indicated that there were no designated behavioral health rooms in the ED, and that each of the ED rooms could be converted into a safe room by removing items in the room. b. Upon request, the facility was unable to provide a policy or procedure for creating a safe environment for converting the rooms for the behavioral health patients in the ED that would guide nursing practice. Stratford F. Based on medical record review, staff interview and review of facility documents, it was determined that the facility failed to ensure that psychiatric screening services are provided at all times in the Stratford Emergency Department (ED). Findings include: Reference: Facility Job Description for "Behavior Health Case Manager" states, " ... Minimum Knowledge, Skills & Abilities ... Education required: Masters in Social Work, Counseling, Human Services Field. Three years experience in behavioral health case management required ... Job/Unit Specific Functions 1. Non Violent CRISIS Intervention. 2. Proficient in providing psychosocial assessment of patients in relation to their illness and health maintenance needs ...". 1. A review of Medical Record #ST6 indicated that the Behavioral Health Screening was completed on 5/22/18 by a Registered Nurse. a. The physician's ROS (Review of Systems) timed 10:22 AM states, " ... Psychiatric: ... Historian reports depression ... Historian reports suicidal ideation ...". b. An order placed at 11:44 AM states, "Medically Cleared for Behavioral Health Evaluation". c. The "Doctor Notes" timed for 1:15 PM states, "Re-evaluation ... Evaluated by ___ Mental Health Screener. No suicidal or homicidal ideation ... Stable for discharge ... ." d. Under the "Nursing Procedure: Transition Care Team" documentation, it states,"... Assessment: Notes: Behavioral Health Nurse Case Manager: ... Pt [Patient] admits to feeling depressed due to [his/her] mother dying 8 years ago ... Pt denies suicidal thought or intent ...". e. The above was confirmed with Staff #ST7. 2. During an interview on 11/28/18, Staff #ST7 revealed the following: a. There is no policy for Behavioral Health evaluations, it is a process, and the Behavioral Health Case Managers are responsible for completing the Behavioral Health Evaluation when the patient is not in Crisis. b. It was confirmed that Staff #ST21, who completed the Behavioral Health Evaluation on Patient #ST6, was not Master's prepared in Social Work, Counseling, or Human Services Field, as required by the facility's job description. c. Behavior Health Case Managers are not available during the full 24 hours of a day. If a psychiatrist consultation is needed for a patient's evaluation, an "informal process" is in place to contact a Psychiatrist. (i) Upon request, an on-call list for a covering Psychiatrist was not provided.

A. Based on medical record review, review of facility policies and procedures, review of facility documents, and staff interview, it was determined that the facility failed to provide evidence of reassessments for patients classified with an ESI level three (3) according to facility policy. Findings include: Reference #1: Facility policy, Assessment/Reassessment (Procedure Steps), states, " ... 6. Reassess the patient as directed by acuity level and/or by the patient condition ... b. Level 3 - every two hours ..." Reference #2: Facility policy, Nursing Documentation for Low Acuity Patients, states, "A full set of vital signs will be taken during initial assessment. Vital signs will be repeated if: a) Patient remains in ED for over 2 hours b) Initial vital signs were outside normal limits, focused at minimum on abnormal parameter." 1. Medical record review, conducted at the Washington Division on 7/24/17, revealed the following: a. Medical Record #1, indicated that the patient (MDS) dated [DATE] at 14:44 with complaints of right leg numbness and tingling and upper extremity weakness. i. The patient was triaged at 14:52, classified as ESI 3, and moved to the Lobby. ii. The patient was reassessed at 14:49, 16:45, 20:03, and 22:24. iii. There is no evidence that the patient was reassessed at 18:45. iv. At 20:03, a Nursing Procedure Communications note states, "Stroke Alert Called." b. Medical Record #4, indicated that the patient (MDS) dated [DATE] at 15:45 with complaints of lower abdominal/back pain. i. The patient was triaged at 16:09, classified as ESI 3, and moved to the lobby. ii. There is no evidence that the patient was reassessed at 18:09 and 20:09. iii. At 21:20, the Nurse's Note states, "pt (patient) called 3 x by this RN (Registered Nurse) with no answer." iv. The patient disposition was "Left Without Treatment." c. Medical Record #6, indicated the patient (MDS) dated [DATE] at 13:09 with complaints of vomiting and weakness. i. The patient was triaged at 13:27, classified as ESI 3, and moved to the lobby. ii. The patient was reassessed at 13:24 and 17:13. iii. There is no evidence that the patient was reassessed at 15:24. iv. At 18:18, the patient disposition was "Left Without Treatment." d. Medical Record #7 indicated the patient (MDS) dated [DATE] at 15:06 with complaints of RLE (right lower extremity) numbness and pain from hip to foot. i. The patient was triaged at 15:17, classified as ESI 3, and moved to the lobby. ii. The patient was reassessed at 15:10. iii. There is no evidence that the patient was reassessed at 17:10 and 19:10. iii. At 19:20, the Nurse's Note states, "called multiple times all areas checked no answer LWT." e. Medical Record #14 indicated the patient (MDS) dated [DATE] at 11:21 with complaints of left flank pain. i. The patient was triaged at 11:42, classified as ESI 3, and moved to the lobby. ii. There is no evidence that the patient was reassessed at 13:42. iii. At 15:24, the Nurse's Note states, "no answer x 2." iv. At 16:01, the Nurse's Note states, "no answer x 3." v. At 16:02, the patient's disposition states, "Left Without Treatment". f. Medical Record #18 indicated the patient (MDS) dated [DATE] at 14:49 with complaints of upper abdominal pain for 2-3 weeks. i. The patient was triaged at 14:56, classified as ESI 3, and moved to the lobby. ii. There is no evidence that the patient was reassessed at 16:56. iii. At 18:37, the Nurse's Note states, "unable to locate patient to take to treatment area." iv. At 18:59, the Nurse's Note states, "Pt. called in lobby, no answer @ 18:58." v. At 19:00, disposition documented as "Left Without Treatment." 2. The above findings were confirmed with Staff #1 and Staff #2. 3. Medical Record review, conducted at the Stratford Division on 7/26/17, revealed the following: a. Medical Record #21 indicated the patient (MDS) dated [DATE] at 13:54 with complaints of vomiting and shortness of breath. i. The patient was triaged at 14:22, classified as ESI 3, and moved to the lobby. ii. The patient was not reassessed at 16:22. iii. At 17:00, the Nurse's Note states, "not in WR (waiting room)." iv. At 18:35, the patient's disposition was documented as "Left Without Treatment." b. Medical Record #22 indicated the patient (MDS) dated [DATE] at 18:26 with complaints of abdominal pain. i. The patient was triaged at 18:51, classified as ESI 3, and moved to the lobby. ii. There is no evidence that the patient was reassessed at 20:51 and 22:51. iii. At 23:24, the patient's disposition was documented as "Left without Treatment." c. Medical Record #23 indicated the patient (MDS) dated [DATE] at 16:22 with complaints of abdominal pain. i. The patient was triaged at 17:45, classified as ESI 3, and moved to the lobby. ii. There is no evidence that the patient was reassessed at 19:45. iii. At 21:04, Triage Assessment documentation states "Patient called x 2, no answer in waiting room." iv. At 22:50, a third attempt was made to locate the patient; the patient's disposition was documented as "Left Without Treatment." 4. The above findings were confirmed with Staff #13 and Staff #23. 5. Medical record review conducted at the Cherry Hill Division on 7/28/17, revealed the following: a. Medical Record #35 indicated the patient (MDS) dated [DATE] at 21:15 with complaints of muscles spasms in back/left flank pain. i. The patient was triaged at 21:53, classified as ESI 3, and moved to the lobby. ii. The patient was reassessed at 02:28. iii. There is no evidence that the patient was reassessed 23:53 and 1:53. iv. At 02:47 on 5/18/17, the patient left Against Medical Advice (AMA). 6. The patients were not reassessed every two hours as indicated in the facility policy. 7. The above findings were confirmed with Staff #13 and Staff #40. B. Based on medical record review, review of facility policies and procedures, and staff interview, 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, "Pain Assessment ... 4. If such assessment identifies a positive pain response, the RN will document in the electronic medical record the assigned pain intensity score and conduct a more detailed assessment of the pain characteristics - also known as a comprehensive pain assessment (CPA): a. location ... d. acceptable level of pain (pain goal) ... Key Points ... Lack of pain expression does not necessarily mean the absence of pain... Pain Assessment Tools ... Numerical Scale ... Moderate = 4-6, Severe = 7-10 ... Pain Reassessment: 1. The reassessment of a patient's pain and the effectiveness of the treatment plan should be ongoing. Pain will be reassessed ... no longer than one (1) hour for pharmacological interventions. 2. Document the reassessed pain intensity on the appropriate form within the electronic medical record." Reference #2: Facility policy, Patient Rights & Responsibilities, states, "... The right to receive pain relief. The right to an appropriate assessment and management of your pain. You have a right to be educated about pain, pain relief measures ..." 1. Medical record review conducted at the Washington Division on 7/24/17 revealed the following: a. Review of Medical Record #4 revealed the following: i. The patient (MDS) dated [DATE] at 15:45 with complaints of lower abdominal/back pain. ii. At 16:06, the patient reported a pain level of nine (9) out of ten (10) on the facility's numeric scale. iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal). iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain. iv. There is no evidence that the patient's pain was reassessed per facility policy. b. Review of Medical Record #6 revealed the following: i. The patient (MDS) dated [DATE] at 13:09 with complaints of vomiting/weakness. ii. At 13:24, the patient reported a pain level of five (5) out of ten (10) on the facility's numeric scale. iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal). iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain. v. There is no evidence that the patient's pain was reassessed as indicated in the facility policy. c. Review of Medical Record #7 revealed the following: i. The patient (MDS) dated [DATE] at 15:06 with complaints of RLE (right lower extremity) numbness and pain from hip to foot. ii. At 15:10, the patient reported a pain level of eight (8) out of ten (10) on the facility's numeric scale. iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal). iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain. v. There is no evidence that the patient's pain was reassessed as indicated in the facility policy. d. Review of Medical Record #11 revealed the following: i. The patient (MDS) dated [DATE] at 21:23 with complaints of suicidal ideation, crisis evaluation, and 8/10 generalized pain. ii. At 21:30, the patient reported a pain level of eight (8) out of ten (10) on the facility's numeric scale. iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal). iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain. e. Review of Medical Record #14 revealed the following: i. The patient (MDS) dated [DATE] at 11:21 with complaints of left flank pain for 3 days. ii. At 11:38, the patient reported a pain level of ten (10) out of ten (10) on the facility's numeric scale. iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal). iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain. v. There is no evidence that the patient's pain was reassessed as indicated in the facility policy. f. Review of Medical Record #18 revealed the following: i. The patient (MDS) dated [DATE] at 14:49 with complaints of upper abdominal pain for 2-3 weeks. ii. At 14:53, the Emergency Flow Sheet Record revealed that the "Pain" section was blank. iii. There was no evidence that a comprehensive pain assessment was performed. 2. The above findings were confirmed with Staff #1, Staff #2, Staff #4 and Staff #6. 3. Medical record review, conducted at the Stratford Division on 7/26/17, revealed the following: a. Review of Medical Record #22 revealed the following: i. The patient (MDS) dated [DATE] at 18:26 with complaints of abdominal pain. ii. At 18:46, the patient reported a pain level of eight (8) out of ten (10) on the facility's numeric scale. iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal). iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain. v. There is no evidence that the patient's pain was reassessed as indicated in the facility policy. b. Review of Medical Record #23 revealed the following: i. The patient (MDS) dated [DATE] at 16:22 PM with complaints of abdominal pain. ii. At 17:41, the patient reported a pain level of eight (8) out of ten (10) on the facility's numeric scale. iii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal). iv. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain. v. There is no evidence that the patient's pain was reassessed as indicated in the facility policy. c. Review of Medical Record #25 revealed the following: i. The patient (MDS) dated [DATE] at 13:42 with complaints of Psych/Right hand injury. ii. At 13:49, the patient reported a pain level of six (6) out of ten (10) on the facility's numeric scale. iii. At 14:31, the patient reported a pain level of seven (7) out of ten (10) on the facility's numeric scale. iv. At 17:08, Nursing Procedure documentation indicated that splinting was performed for fracture care and pain control. v. The Medication Administration Summary indicated that Ibuprofen/Motrin was given on 1/6/17 at 16:51, 23:24, and on 1/7/17 at 16:36. vi. Documentation at 15:30 and 17:30 lacked evidence of a pain assessment. vii. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal). vii. There is no evidence that the patient's pain was reassessed as indicated in the facility policy. d. Review of Medical Record #26 revealed the following: i. The patient (MDS) dated [DATE] at 23:44 with complaints of right arm pain after a fall. ii. At 23:50, the patient reported a pain level of four (4) out of ten (10) on the facility's numeric scale. iii. There is no evidence that an acceptable level of pain (pain goal) was established as indicated in the facility policy. e. Review of Medical Record #30 revealed the following: i. The patient (MDS) dated [DATE] at 10:36 with complaints of chest pain. ii. At 10:38, the patient reported a pain level of eight (8) out of ten (10) on the facility's numeric scale. iii. At 11:10, the patient was given Aspirin 325 mg (milligram) by mouth. iv. At 11:55, the patient was given Ativan 1 mg intravenously. v. There is no evidence that the patient's pain was reassessed as indicated in the facility policy. vi. There is no evidence that an acceptable level of pain (pain goal) was established as indicated in the facility policy. 4. The above findings were confirmed with Staff #13 and Staff #23. 5. Medical Record review, conducted at the Cherry Hill Division on 7/28/17 revealed the following: a. Review of Medical Record #39 revealed the following: i. The patient (MDS) dated [DATE] at 20:27 with complaints of abdominal pain. ii. At 20:34, the patient reported a pain level of ten (10) out of ten (10) on the facility's numeric scale. iii. At 21:00, Morphine 4 mg intravenous (IV) was ordered for the patient. iv. At 21:10, pain reassessment revealed pain level of six (6) out of ten (10), pain medication was held, reason stating "Pain controlled at present ..." v. There is no evidence that a comprehensive pain assessment was performed, including but not limited to, establishing an acceptable level of pain (pain goal). vi. There is no evidence of the use of non-pharmacological interventions to manage the patient's pain. 6. The above findings were confirmed with Staff #13 and Staff #40. C. Based on medical record review, review of facility policy and procedure, and staff interview, it was determined that the facility failed to ensure that all reasonable steps to secure the individual's written informed refusal of treatment was obtained. Findings include: Reference #1: Facility policy, Leaving the Emergency Department Without Treatment, states, "...Procedure: ...Risks associated with leaving before evaluation and treatment will be reviewed with patient. Triage nurse/designee will document discussion of risks. Patient will be asked to sign a left without treatment form (located in the electronic record). If patient choose not to sign, triage nurse/designee will document refusal. If patient is called in the lobby and cannot be found, two additional attempts will be made to locate the patient before the patient is designated without treatment. The triage nurse/designee will document each attempt to locate patient ..." 1. Medical record review revealed that six (6) out of 6 medical records (#4, #6, #7, #21, #22, #23) of patients that left the facility without treatment did not contain a signed "Left Without Treatment" form. 2. Medical record review revealed that five (5) out of six (6) medical records (#4, #6, #7, #22, #23) of patients that left the facility without treatment did not contain written documentation of refusal to sign. 3. Medical record review revealed that five (5) out of six (6) medical records (#4, #6, #7, #22, #23) of patients that left the facility without treatment did not contain written documentation of three individual attempts to locate the patient before the patient was designated as left without treatment. 4. The above findings were confirmed with Staff #4, Staff #6, Staff #13, Staff #23, and Staff #40.

Based on observation, review of facility policy and procedure, and staff interview, 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, Signage Meeting Regulatory Standards (EMTALA), states, "... 2. Location of the signage is as follows: Lobby, Admissions, All public entrances, ED waiting area, ED Triage Room, Labor and Delivery Rooms ..." 1. A tour of the Washington Township Division, conducted on July 21, 2017, revealed that there were no EMTALA signs posted in the following areas: a. Hospital main entrance/Lobby b. ED entrance c. ED ambulance entrance d. ED triage area e. ED Intake Rooms #1 through #4 f. ED Medical Screening Area #1 and #2 g. ED Acute Results Waiting Lounge #2 h. ED Acute Room #15 i. ED Subacute Room #24 j. ED Acute Hallway Areas #1 through #10 k. Labor and Delivery Triage Hallway #79 and #80 2. A tour of the Washington Township Division, conducted on July 21, 2017, revealed that the EMTALA signs posted in the following areas were not visible to patients and visitors: a. Results Waiting Area b. Labor Room #73 3. These findings were confirmed by staff #1 and Staff #2. 4. A tour of the Stratford Division, conducted on July 25, 2017, revealed that there were no EMTALA signs posted in the following areas: a. Hospital main entrance/Lobby i. The above was confirmed with Staff #4 and Staff #13. b. ED Intake/Pivot room c. ED Triage area d. Results Waiting (recliner area) e. ED Room #3, #4, #7, #8, #10, and #11 f. ED Hallway stretcher #1, #2, and #4 g. ED Ready Room area #1 h. ED Satellite area A, B, C, and D i. ED Express area A, B, C, and D j. Observation room(s) on non-designated units throughout the facility i. The above was confirmed with Staff #2. 5. A tour of the Stafford Division, conducted on July 25, 2017, revealed that the EMTALA signs posted in the following areas were not visible to the patients: a. ED entrance b. ED Ready Room areas #2, #3, and #4 6. The above findings were confirmed by Staff #2, and Staff #23. 7. A tour of the Cherry Hill Division, conducted on July 27, 2017, revealed that there were no EMTALA signs posted in the following areas: a. The Garage and Surface parking entrance i. The above was confirmed with Staff #2, Staff #5, and Staff #13. b. Hospital main entrance i. The above was confirmed with Staff #2, Staff #5, and Staff #13. c. ED Triage Rooms #1 and #2 d. ED Trauma area A and B e. ED ECG (Electrocardiogram) wait and treatment room f. ED Rooms #1 through #12 g. ED Results Pending (recliner area) h. ED Express Care area A, B and C i. ED Treatment Rooms #14, #16, #17, and #18 j. Observation room(s) on non-designated units throughout the facility i. The above was confirmed with Staff #2. 8. A tour of the Cherry Hill Division, conducted on July 27, 2017, revealed that the EMTALA signs posted in the following areas were not visible to patients and visitors: a. ED entrance b. ED Treatment Room #15 9. The above findings were confirmed by Staff #2, Staff #40 and Staff #41.

Based on medical record review, review of facility policy and procedure, and staff interview, it was determined that the facility failed to provide an appropriate patient transfer. Findings include: Reference: Facility policy, Transfer of Patients, states, "... The patient is informed of his/her rights (Emergency Medical Treatment and Active Labor Act 1986). ...Purpose To ensure the appropriate transfer of a patient from one facility to another. Steps The ED Physician Will: ...2. Explain risks and benefits of transfer to the patient and/or family 2. Key Points 2. Informed consent should be documented. Risks discussed should include accident during transport and complications occurring during transport. The Physician Will ...3. Complete authorization for transfer consent form and have patient or family member sign. ...The ED Nurse or designee will: ...8. Contact the receiving nurse including: -time of departure -equipment to be returned -personnel accompanying patient -mode of transport and ETA -patients current condition Key Points Document all information in EDIS. ..." 1. Medical records reviewed at the Washington Township Division on 7/24/17, revealed the following: a. Medical Record #11 had an "Authorization for Transfer" form that failed to include the patients signed consent to transfer. b. Medical Record #12 had an "Authorization for Transfer" form, completed by the physician, that failed to include the date and time. i. There was no evidence that the ED Nurse or designee contacted the receiving facility nurse regarding Patient #12's transfer. 2. The above findings were confirmed with Staff #6. 3. Medical records reviewed at the Stratford Division, revealed the following: a. Medical Record #25 had an "Authorization for Transfer" form that failed to include the patients signed consent to transfer. i. Medical Record #25 lacked evidence that a verbal report was given to the receiving facility nurse. ii. The above findings were confirmed with Staff #23. b. Medical Record #28 had an "Authorization for Transfer" form that failed to include physician's signature. 4. The above finding was confirmed with Staff #4 and Staff #13.

Based on a review of the ED on-call schedule for the Washington Township Division and staff interview on July 24, 2017, it was determined that the facility failed to ensure that written policies and procedures are in place to respond to situations in which a particular specialty is not available. Findings include: 1. Review of the Department of Surgery on-call schedule, revealed the following: a. There was no coverage for Thoracic surgery on 5/20/17, 5/27/17, 5/28/17, 5/29/17, 6/3/17, 6/4/17, 6/16/17, 6/17/17, 6/18/17, 7/1/17, 7/2/17, 7/4/17, 7/8/17, and 7/9/17. 2. Upon request, Staff #1 was unable to produce written policies and procedures that respond to situations in which a particular specialty is not available. 3. The above findings were confirmed by Staff #1.

A. Based on review of the facility document titled, "Medical Staff Code of Conduct Rules and Regulations Bylaws" and staff interview, it was determined that the facility failed to ensure that the medical screening exam (MSE) was conducted by individuals who are determined qualified by hospital bylaws or rules and regulations. Findings include: 1. On 7/28/17 review of the facility document titled, "Medical Staff Code of Conduct Rules and Regulations Bylaws" lacked evidence of a definition of a QMP (qualified medical personnel). 2. Upon interview on 7/28/17, Staff #4 stated that the QMP would be a person that goes thru the credentialing process. 3. The facility failed ensure that the MSE was conducted by individuals who are determined qualified by hospital bylaws or rules and regulations. 4. The above findings were confirmed with Staff #4. B. Based on medical record review, review of facility documents, and staff interview, it was determined that the facility failed to ensure patient's MSE are prioritized appropriately. Findings include: 1. Review of Medical Record #19, at the Washington Township Division on 7/24/17, revealed the following: a. According to the patient's face sheet, the patient was admitted on [DATE] at 07:51. b. The Patient's quick registration was completed on 7/16/17 at 15:24. c. The "Daily Log in Labor and Delivery" states, the patient's "Time in" was 15:50. The MSE was completed at 16:17. 2. Upon interview, Staff #22 stated that sometimes L&D (Labor and Delivery) patients go directly to the unit. The time on the face sheet is the time that the full registration is completed. a. The full registration was completed on 7/18/17 at 07:51. b. The admission time on 7/16/17 was therefore reflective of the time that the patient was fully registered on 7/18/17. 3. Review of Medical Record #20, at the Washington Township Division on 7/24/17, revealed the following: a. According to the patient's face sheet, the patient was admitted on [DATE] at 09:40. b. The Patient's quick registration was completed on 7/3/17 at 16:45. c. The "Daily Log in Labor and Delivery" states, the patient's "Time in" was 16:50 PM. The MSE was completed at 18:11. 4. Upon interview, Staff #22 stated the time on the face sheet is the time that the full registration was completed. a. The full registration was completed on 7/5/17 at 09:40. b. The admission time on 7/3/17 was the time the patient was fully registered on 7/5/17. 5. The facility failed to ensure that an accurate admission time was on the patient's face sheet. Due to the inaccurate admission time, the facility was unable to determine if the MSE was prioritized appropriately under the EMTALA law. 6. The above findings were confirmed with Staff #1 and Staff #22. C. Based on document review and staff interview it was determined that the facility failed to ensure all patients presenting to the ED are provided with a medical screening exam. Findings include: Reference #1: Facility policy, Emergency Care Compliance, states, "... Once EMTALA is triggered, the Hospitals must not delay in providing a medical screening examination ..." 1. Documentation in Medical Record #4 revealed the following: a. The patient (MDS) dated [DATE] at 15:45 with a complaint of lower abdominal and back pain. b. The patient was triaged at 16:09, classified as ESI 3, and moved to the ED lobby. c. The patient left the ED on 7/19/2017 at 21:20, five hours and thirty-five minutes after arrival. d. There was no documentation of a MSE being completed by a QMP, for this patient. 2. Documentation in Medical Record #6 revealed the following: a. The patient (MDS) dated [DATE] at 13:09 with a complaint of vomiting and weakness. b. The patient was triaged at 13:27, classified as ESI 3, and moved to the ED lobby. c. The patient left the ED on 6/22/2017 at 18:18, five hours and nine minutes after arrival. d. There was no documentation of a MSE being completed by a QMP, for this patient. 3. Documentation in Medical Record #7 revealed the following: a. The patient (MDS) dated [DATE] at 15:06 with a complaint of right lower extremity numbness and pain from the hip to the foot. b. The patient was triaged at 15:17, classified as ESI 3, and moved to the ED lobby. c. At 19:24, the patient was moved from the ED lobby to Sub-Acute Hall #19. d. At 19:31, the patient was moved from Sub-Acute Hall #19 to the ED lobby. e. At 19:20, the Nurse Note states, "Called multiple times all areas checked no answer LWT (left without treatment)." f. The patient disposition states, "Left Without Treatment/LWT" on 6/22/2017 at 19:33. g. The patient left the ED on 6/22/2017 at 19:33, four hours and twenty-seven minutes after arrival. h. There was no documentation of a MSE being completed by QMP, for this patient. 4. Documentation in Medical Record #22 revealed the following: a. The patient (MDS) dated [DATE] at 18:26 with a complaint of abdominal pain. b. The patient was triaged at 18:51, classified as ESI 3, and moved to the ED lobby. c. At 23:09, the patient was moved from the ED lobby to ED #11. d. At 23:20, the patient was moved from ED #11 to the lobby. e. A 22:50, the Nurses Note states, "Attempted to call patient back to be seen but unable to find patient." f. The patient disposition states, "Left Without Treatment/LWT" on 1/6/2017 at 23:24. g. The patient left the ED on 1/6/2017 at 23:24, four hours and fifty-eight minutes after arrival. h. There was no documentation of a MSE being completed by a QMP, for this patient. 5. Documentation in Medical Record #23 revealed the following: a. The patient (MDS) dated [DATE] at 16:22 with a complaint of abdominal pain. b. The patient was triaged at 17:45, classified as ESI 3, and moved to the ED lobby. c. The Triage assessment at 21:04 states, "Patient called x (times) 2, no answer in waiting room." The total time from arrival in ED to being called was four hours and forty-two minutes. d. The documented assessment in "Triage" of the ED record at 22:50 states, "Patient called for a third time, no answer in waiting room. Patient name will be taken off board." e. The documented disposition of the patient in the ED record was "Left Without Treatment/LWT" on 1/6/2017 at 22:50. f. The patient left the ED at 22:50, six hours and twenty-eight minutes after arrival. g. There was no documentation of a MSE having been completed by a QMP, for this patient.