Based on findings from document review and interview, the hospital failed to comply with the requirements at 489.24 and related requirements at 489.20. Please reference findings at Tag 2408.

Based on findings from document review, interview, and video surveillance review, the hospital did not facilitate the transport of a patient from outside the Emergency Department (ED) entrance into the ED which delayed triage, medical screening exam (MSE) and treatment. Specifically, in 1 of 20 (Patient #1) medical records (MRs) reviewed. This delay could lead to untoward patient outcomes. Findings include: -- Review of the facilty's policy and procedure titled "EMTALA - Screening, Stabilization, Management of Transfers and Recordkeeping; Reporting Suspected EMTALA Violations," last revised 9/1/17, indicated a medical screening examination and/or stabilizing treatment may take place within a dedicated ED or elsewhere on hospital property. Hospital property includes the main campus, hospital's parking lots, sidewalks and driveways, plus hospital departments or buildings that are within 250 yards of the hospital's main building. -- Review of Patient #1's MR revealed the following: EMS (Emergency Medical Services) documentation on 9/5/17 at 6:53 pm revealed EMS was called to the ED entrance after Patient #1's mother was told by hospital staff at the ED that they could not help bring her daughter (9-year-old female) into the ED following a fall off a swing. ED staff stated "no, they can't help" the patient needed to be brought in by stretcher, so the mother called 911 for assistance. Upon arrival, the patient was in the backseat of the mother's car located in the ambulance space outside the ED emergency doors. Patient #1 was placed in a cervical collar and secured on a pediatric-board, then placed on a stretcher and wheeled into ED. -- Review of video surveillance of 9/5/17 at 6:30 pm revealed the following: 6:30 pm - Mother of Patient #1 entered the ED and spoke with the Staff A (Security Guard). 6:32 pm - The security guard then took the mother to speak with the triage nurse. 6:34 pm - Patient #1's mother was speaking with the triage nurse, then walked to the ED entrance. 6:34 pm - The Security Guard went inside the exam area and could not be seen. 6:36 pm - The Security Guard returned and spoke to Patient # 1's mother and explained something. 6:37 pm - The mother went back outside and returned to her vehicle. 6:50 pm - Local Fire Department truck arrived and talked with Patient #1 and her mother. 6:53 pm - EMS arrived, stabilized Patient #1 and placed her on a stretcher. 7:03 pm - EMS brought the patient into the ED. There was a 33 minute delay for triage, medical screening exam (MSE) and treatment of Patient #1 from the arrival to the hospital property until EMS transported her into the ED. -- Per interview of Staff A (Security Guard) on 9/12/17 at 11:08 am, Patient #1's mother presented to the ED and stated her daughter fell off a bridge at the park, hurt her back and has a lot of pain. Staff A spoke to the triage nurse who instructed him/her to inform the charge nurse. The charge nurse told Staff A "there is nothing we can do, it's a liability, you will have to call 911." He/she returned to the waiting room in the ED and informed Patient #1's mother she would have to call 911. The mother then went outside and called 911. He/she did not see any ED staff go outside to evaluate the patient. -- Per interview of Staff B (RN Charge Nurse ED) on 9/12/17 at 11:25 am, a staff member came to him/her and explained a child had neck and back injuries after falling several feet onto her head. Staff B stated "he/she is not trained to extricate a patient from the car and felt it was best to call EMS. The patient had a potential neck and spine injury. It's not that we refused to treat the patient but felt it was the safest option for the patient." He/she did not inform the ED Physician of the circumstances involving this patient. Staff B was not aware of any ED staff evaluating the patient outside in their vehicle. Staff B also indicated the ED doesn't have the appropriate equipment to stabilize patients, no back boards are available in the ED and he would have to search through the EMS lockers to find equipment. -- Per interview of Staff C (Medical Director ED) on 9/11/17 at 9:15 am, if a patient is in a car and requesting assistance, the Security Guards can assist. If it is due to medical reasons, a nurse would be notified. "With trauma cases, it can get tricky for legality issues, whether a provider should go outside." Sometimes they would call the resource center "911 to assist" for extra help or if EMS providers were on site they would ask for assistance. It all depends on where on the property the patient is. If someone was having a heart attack they would run outside and bring the patient in. -- During interview of Staff D (Nurse Manager ED) on 9/12/17 at 1:53 pm, he/she indicated, there is always equipment available to stabilize a patient (e.g., cervical collar, back board). The ED providers are all trained to apply the cervical collar and backboard to stabilize a patient. He/she would not expect staff to call 911 for a patient on hospital property.

Based on findings from document review, medical record review and interview, the hospital failed to comply with the requirements at 489.24 and related requirements at 489.20. See Tag A2404.

Based on medical record (MR) review, document review, and interview, the facility did not ensure the following: 1) in 1 of 12 MRs reviewed (for patients requiring on call physician services), the on-call provider refused to make an in-person appearance to evaluate and treat an unstable individual. 2) In 4 of 12 MRs reviewed (for patients requiring on-call physician services), the on-call provider did not respond timely to emergency department (ED) physician's calls. 3) The hospital on-call list for surgeons does not consistently identify the individual physician who is responsible for call. 4) The hospital policy and procedure (P&P) for on-call physicians did not clearly outline the duties and responsibilities of the physician on-call and did not address all regulatory requirements. These lapses could lead to untoward patient outcomes. Findings regarding (1) above include: -- Review of Patient #1's MR, the Patient was brought to the ED (via ambulance) on 6/5/17 at 10:45 pm after a motor vehicle accident with loss of consciousness. He was triaged as a level 1 (on 1-5 scale, 1= requires immediate life-saving intervention). At 11:51 pm, the on-call surgeon, Staff B was called. Staff were unable to reach him/her. However, at 12:07 am (on 6/6/17), documentation reveals Staff A (ED Physician) spoke to an on-call surgeon, Staff C (from Staff B's surgical group.) Staff C refused to come to the ED to evaluate the patient. He/she instructed Staff C to transfer Patient #1 to the local trauma center (Hospital A). -- Per review of the hospital's P&P titled "EMTALA: Emergency Medical Treatment and Active Labor Act- Screening, Stabilization, Management of Transfers and Recordkeeping; Reporting Suspected EMTALA Violations," dated 3/16/17, "When a physician is on call ... it is not acceptable to refer or transfer unstable cases ... the physician must come to the hospital to examine the individual." -- Per interview of Staff A on 7/28/17 at 1:00 pm, Patient #1 had severe back pain, hypotension (low blood pressure), and positive loss of consciousness. When he/she asked the on call surgeon (Staff C) to come in to examine Patient #1, he/she refused and told Staff A the patient needed to be sent to a trauma center. -- Per interview of Staff C on 7/28/17 at 2:15 pm, regarding Patient #1, he/she was paged and responded. After Staff A explained the patient case he/she recommended to "resuscitate the patient and transfer to the trauma center." The patient needed critical care. He/she stated he did not refuse to see the patient but "wanted the patient resuscitated and transferred." He did not come in to see the patient. Findings regarding (2) above include: -- Per review of the facility's P&P titled "EMTALA: Emergency Medical Treatment and Active Labor Act- Screening, Stabilization, Management of Transfers and Recordkeeping; Reporting Suspected EMTALA Violations," dated 3/16/17, it indicated the on-call physicians' responsibility to respond, examine and treat emergency patients is set forth in the facility's Medical Staff Rules and Regulations. -- Review of the facility's "Medical Staff Policies (Rules and Regulations)" last revised 6/2017, revealed that the member on call is to respond to the ED when requested by the ED practitioner by telephone call within 20 minutes. In addition, response time in emergency situations surgeons, anesthetists and obstetrician must be in the physical presence of the patient within 30 minutes. -- Per review of Patient #2's MR, on 6/5/17 at 8:13 am, she presented to the ED (via ambulance) with abdominal pain and hypotension. She was triaged as a level 2 (condition has potential to threaten life, limb, visual function, requires rapid medical intervention, should not wait to be seen). At 8:15 am, Staff D evaluated the patient. At 11:13 am, Staff D (ED Physician) discussed the patient with on-call surgeon (Staff C) and he agreed to see the patient. At 12:43 pm (1 hour and 30 minutes later), Staff C arrived at the ED to evaluate Patient #2. -- Per review of Patient #3's MR, on 5/8/17 at 3:07 pm, he presented to the ED with a right thumb traumatic amputation. He was triaged as a level 2. At 3:34 pm, Staff E (ED Physician) called the on-call provider (Staff F) and left a message. At 3:51 pm, another message was left. At 4:40 pm (59 minutes later), Staff F, the on-call provider called back. (Contact was made with another facility at 4:05 pm. That facility called back at 4:15 pm and after discussion indicated Patient #3's thumb could not be reattached so patient should stay there.) -- Per review of Patient #5's MR, on 3/23/17 at 1:50 am, she presented to the ED with abdominal and groin pain. She was triaged as a level 3 (require two or more resources, but less urgent). At 5:28 am, Staff G called the on-call surgeon (Staff C). Staff C responded and stated he/she understood the patient needed surgery and he/she would make a few phone calls. At 5:40 am (12 minutes later), Staff C telephoned and stated he/she would see the patient in the hospital and agreed to admit the patient. At 8:46 am (3 hours and 6 minutes later), the patient was taken to surgery by Staff H (Surgeon). Consultation documentation revealed the on-call surgeon (Staff C) did not present to the hospital ED but indicated he would meet Staff H in the operating room. -- Per review of Patient #4's MR, on 7/3/17 at 9:29 am, he presented to the ED (via ambulance) with left shoulder pain and swelling after being thrown from a bicycle. He was triaged as a level 2. At 11:11 am, the on-call surgeon (Staff B) was called, and a message was left. At 11:35 am, and 11:58 am, additional messages were left for Staff B. At 12:01 pm, Staff I (ED Physician) consulted with Staff J (Cardiothoracic Surgeon) who provided treatment orders. At 12:08 pm, a trauma surgeon from another hospital (Staff K) was contacted and he/she accepted the patient for transfer. The MR lacks documentation of any return call from Staff B, the on-call surgeon. -- During interview of Staff L (Director of Quality Management) on 7/31/17 at 2:00 pm, he/she acknowledged the above findings. Findings regarding (3) above include: -- Review of the facility's surgery on-call list for June and July of 2017, identified the following: on June 1, 5 (date of the index case), 9, 17, 21, 25, 29, 2017 and July 3, 7, 19, 27, 31, 2017, Staff B is listed as the on-call surgeon. However, per interview of Staff M (ED Medical Director) on 7/28/17 at 10:40 am, he/she confirmed that Staff B's name indicated his/her surgical group is on call. It may be one of the three surgeons in the group, not specifically Staff B. -- Per interview of Staff N (Chief Medical Officer) on 7/28/17 at 11:00 am, he/she stated there is no formal communication with this surgical group to indicate which specific physician is on call. -- Per interview of Staff L on 7/28/17 at 12:50 pm, he/she stated the head of the surgical group is listed on the on-call list and the group decides who is on call. He/she was not sure who exactly was on call on 6/5/17. Findings regarding (4) above include: -- Per review of the hospital's P&P titled "EMTALA: Emergency Medical Treatment and Active Labor Act- Screening, Stabilization, Management of Transfers and Recordkeeping; Reporting Suspected EMTALA Violations," dated 3/2017, and the hospital's "Medical Staff Rules and Regulations," last revised 6/2017, these documents did not address simultaneous call or contain a back up procedure when the on-call physician is not available to respond. -- During interview of Staff N (Chief Medical Officer) on 7/28/17 at 11:15 am, he/she acknowledged the above findings.

Based on findings from medical record (MR) review and interview, the emergency department (ED) did not ensure that emergency care was provided in accordance with generally accepted standards. Specifically, 1) in 1 of 10 MRs, an ED Attending Physician did not ensure that a physical evaluation of a patient was documented in the MR, 2) in 2 of 10 MRs, nursing staff did not document patient assessments and the ED lacked a policy and procedure (P&P) that addressed patient assessment by nursing staff, and 3) in 3 of 10 MRs, nursing staff did not document patient vital signs at the time of discharge. This could cause staff to have lack of awareness a patient was unstable. Findings regarding (1) include: -- Review of Patient #1's MR revealed that he (MDS) dated [DATE] at 11:36 pm with complaints of back pain, numbness in both legs, and shortness of breath. He was assigned a triage level 3 (on 1-5 level acuity scale with 1 being the most acute). Vital signs obtained at 11:43 pm revealed blood pressure (BP) 134/85, pulse (P) 115, oxygen saturation (O2 Sat) on room air 99%, respirations (R) 17 and temperature (T) 36.6 degrees Celsius. At 12:08 am (5/10/17) Staff A (ED Nurse Practitioner (NP)) evaluated the patient and documented: The patient's presenting symptoms were moderate stiffness to the lumbar back. The patient denied any fall, and stated he stepped wrong and almost fell . The patient had a recent infection of cellulitis. A review of all systems was negative except for back pain and stiffness. An EKG and laboratory work were completed. EKG revealed sinus tachycardia. Laboratory results were all within normal limits apart from the C-reactive Protein (CRP), which was elevated at 49.4 mg/L (normal range is 0.0-5.0 mg/L). At 2:57 am, Staff A documented the ED Attending Physician had examined the patient. -- Per interview of Staff A on 6/22/17 at 12:00 pm, he/she requested the ED physician assistance regrading what type of CT scan to order. -- Per interview of Staff B (ED Attending Physician) on 6/21/17 at 11:40 am, he/she examined Patient #1 and didn't need to document a completed assessment because he/she agreed with Staff A (ED NP)'s assessment of the patient. He/she stated the patient had no history of pulmonary embolism, was hemodynamically stable, neurovascular system intact, pulses were positive, no fever, no discoloration of the legs and the patient complained more about back pain. He/she spoke to patient and told him a CT scan of the lower back was not required. There was no documentation by the ED Attending Physician in the MR of a physical examination of the patient. -- Per interview of Staff C (Medical Director) on 6/21/17 at 12:15 pm, he/she acknowledged the lack of a documented assessment of the patient by the ED Attending Physician. Findings regarding (2) include: -- Review of Patient #1's MR revealed he (MDS) dated [DATE] at 11:36 pm with complaints of back pain, numbness in both legs, and shortness of breath. The patient was triaged at 11:43 pm and revealed the patient had a recent cellulitis. (location not documented) Patient #1 was discharged from the ED on 5/10/17 at 2:18 am. There was no documentation indicating that nursing staff performed a physical assessment of the patient that focused on the patient's presenting complaint. -- Review of Patient #2's MR revealed he (MDS) dated [DATE] at 1:25 am with recent seizure activity. The patient was triaged at 1:51 am and revealed the patient had no medical or surgical history. Patient #2 was discharged from the ED to home at 3:59 am. There was no documentation indicating that nursing staff performed a physical assessment of the patient that focused on the patient's presenting complaint. -- During interview of Staff D (ED Nurse Manager) on 6/22/17 at 2:15 PM, he/she acknowledged the lack of hospital P&P addressing nursing assessments (including vital signs) in the ED. He/she stated that every patient should have a focused assessment that includes the chief complaint, allergies, pain, fall risk, social history, and nursing diagnosis. It is expected the RN will complete nursing assessments and vital signs based on clinical judgement. He/she acknowledged the lack of nursing assessment in the above MRs. Findings regarding (3) include: -- Review of Patient #2's MR revealed he (MDS) dated [DATE] at 1:25 am with recent seizure activity, was triaged at 1:51 am, and vitals were completed. Patient #2 was discharged at 3:59 am with a temperature (T) of 98.7 degrees Fahrenheit and pain level of 0. There was no documentation that a complete set of vital signs were obtained prior to discharge. -- Review of Patient #3's MR revealed she (MDS) dated [DATE] at 5:26 am with right sided facial pain, was triaged at 5:31 am, and vitals were completed. Patient #3 was discharged at 10:51 am. There was no documentation of a complete set of vitals prior to discharge. -- Review of Patient #4's MR revealed he (MDS) dated [DATE] at 10:37 pm with right leg numbness and pressure in the head, was triaged at 10:42 pm, and vitals were completed. Patient #4 was discharged on [DATE] at 1:54 am. There was no documentation of a complete set of vitals prior to discharge. -- Per interview of Staff D on 6/22/17 at 3:10 pm, the above findings were acknowledged.

Based on findings from observation, interview and document review, the adult and pediatric crash carts in the Emergency Department (ED) were not maintained with adequate supplies. This could result in a delay of treatment in an emergent situation. Additionally, the policy and procedure (P&P) regarding crash carts did not identify which staff are responsible for the crash cart maintenance. Findings include: -- During observation while touring the ED on 1/27/16 at 9:54 am, the adult crash cart content checklist was compared to the contents of cart and revealed multiple items were lacking, (e.g., butterfly needles, yankauer suction, naso-gastric tube and spinal needle.) -- Per interview of Staff #1 on 1/27/16 at 10:05 am, the above finding was acknowledged. -- During observation on 1/27/16 at 10:20 am, the pediatric crash cart content checklist was compared to the contents of cart and revealed multiple items were lacking, (e.g., Ezio driver, intraosseous module and infant nasal cannula.) -- Per interview of Staff #2 on 1/27/16 at 10:30, the above finding was acknowledged. -- Per review of the facility P&P titled "Maintenance of Code Blue Equipment Procedure," last revised 8/10/15, it lacked guidance regarding which ED staff member is responsible for restocking and cleaning crash cart after a code. Also the specific cleaning agent was not listed, the P&P stated the following: "hospital approved disinfectant." -- Per interview of Staff #3 on 1/28/16 at 11:00 am, the above finding was confirmed.

Based on findings from medical record (MR) review and interview, the medical screening examination (MSE) performed for Patient A did not provide assurances his condition was stabilized at the time of discharge. Also, despite request by local law enforcement that it be notified when the patient was discharged , notification did not occur Findings include: --Review of Patient A's MR revealed that the MSE performed for this patient who was brought in on a 9.41 Mental Hygiene Law emergency admission status, was not complete. It did not include evaluation of a report the patient was abusing animals pre-admission and did not include a mental health assessment by a Licensed Clinical Social Worker (LCSW), as ordered by the attending ED physician (Physician #1). See details in findings in Tag 2406. As a result, the MSE performed did not provide assurances the patient's condition was stabilized at the time of discharge. --Also, the form titled "Law Enforcement Request for Examination," completed by the local police department (LPD), dated 1/6/15 and signed at 1405, indicated that if the patient did not require inpatient/psychiatric/medical services, the delivering police agency should be notified prior to release. Phone number of police agency contact is present on the form. Review of Patient A's MR reveals there is no documentation the LPD was notified of the patient's discharge. During interview with RN #1 on 1/12/15 at 1315, he/she was not aware that the LPD wanted to be notified when the patient was discharged .

Based on findings from medical record (MR) review, interview, and facility document review, the hospital failed to ensure that a patient who presented to the emergency department (ED) with signs of psychiatric disorder received a medical screening examination (MSE) that included a complete mental health assessment (MHA). Personnel involved in the patient's care did not obtain, document and/or consider all significant clinical information pertinent to the patient's management. Findings include: --Review of Patient A's medical record on 1/8/15 revealed the following information: On 1/6/15 at 1343 information on a form titled "EMS Communication Sheet" indicates emergency medical services (EMS) personnel contacted the ED regarding transport of a male who had been taken into custody by local police department staff (LPD) for a 9.41 Mental Hygiene Law (MHL) emergency admission. (MHL 9.41 indicates peace or police officers may take custody of and transport to a hospital or comprehensive psychiatric emergency program (CPEP) "any person who appears to be mentally ill and is conducting himself or herself in a manner which is likely to result in serious harm to the person or others.") EMS reported the patient was "homicidal uncooperative." A report titled "PM EMSCHARTS " (a pre-hospital EMS care report), dated 1/6/15 and timed 1423 (faxed time), indicates the patient was MHL status 9.41, impression was behavioral/psychiatric disorder. The report also contains the following statements: " ...pt (patient) admits to using heroin. pt. is combative on attempts to start any ALS (advanced life support) procedure. Per ... (local police department) pt has been abusing animals in his apartment. Pt seems delusional and stated I am the god of war. Pt admits to taking heroin and drinking alcohol. Pt is combative when attempting any assessment. Pt remained in ... handcuffs and put on stretcher through out treatment ... " A form titled "Law Enforcement Request for Examination" completed by LPD, dated 1/6/15 and signed at 1405, indicates the patient's family reported strange bizarre behavior and animal abuse and that the police officer observed "confused, disoriented threats." Information on the form further describing patient behaviors included the following: verbal threats and physical gestures of harm to others, attempted to harm others, yelling and screaming, pushing others, incoherent /illogical speech, talking to self, failure to respond to questions, reported hearing voices, extreme slow speech, hostile, argumentative belligerent, overly suspicious/feeling of persecution, confused/disoriented, hyperactivity, nodding out, appears insensitive to pain. The form indicates there was a potential for violence and restraints/cuffs were being used on the patient. A form titled "Emergency or CPEP Emergency Admission (Sections 9.41, 9.45, 9.55 and 9.57 Mental Hygiene Law) Custody Transport of a Person Alleged to be Mentally Ill to a Hospital Approved to Receive Emergency or CPEP Emergency Admissions (OMH 474A/476A), completed by a police officer on 1/6/15 at 1404, indicates Patient A was taken into custody by law enforcement for transport to the Faxton-St. Luke's Healthcare ED. The following information is recorded by nursing staff in the electronic MR (EMR) and by physician staff on a hardcopy form titled "Emergency Provider Record- Psych Disorder, Suicide Attempt, Overdose " : At 1355, Registered Nurse (RN) #1 triaged the patient as level 2 (on 5 level acuity system, 1 being most acute), documented the chief complaint was "combative psychiatric evaluation," and that "Patient staring into space when EMS called his name and responded who's ... (name)? "He/she also noted the LPD requested 4 point restraints upon arrival, patient was placed in restraints per order of Physician #1 (the attending ED physician), the patient was yelling out, attempting to fight, and security was in the room. At 1415, Physician #1 saw the patient. His/her documentation included/indicated the following: "EMS arrival 9.41 by local police department with chief complaint of agitation ... the agitation was sudden in onset and mild in severity ... no history from patient at this time." Initially the patient was not able to give any information (was "dazed"). Patient descriptors included in the documentation included hostile, paranoid, anxious, depressed. After discussion with the patient, he did not have suicidal or homicidal ideations. Suicide risk assessment revealed the patient was depressed, had hallucinations, and family was frightened; estimated risk for suicide was low. The patient had a past history of a head injury which involved a foreign body in September, and his social history was positive for drugs (marijuana). Physical examination performed with no remarkable findings. At 1425, Physician #1 ordered blood and urine laboratory testing that included basic metabolic panel (BMP), complete blood count (CBC), thyroid stimulating hormone (TSH) and urine drug screen, which were obtained. Urine drug screen showed THC (tetrahydrocannabinol/marijuana). At 1707, Physician #1 ordered "Consult Case Management ED Referral Needs: Discharge Planning." (Per interview with Physician #1 on 1/12/15 at 1130, the electronic component of the MR does not allow order for mental health assessment (MHA) to be entered specifically. When he/she enters an order for a MHA by a social worker in the EMR, he/she clicks on "case management consult for mental health- discharge planning " which means full mental health evaluation by social work and recommendations, e.g., admit, discharge and/or obtain services). There was no documentation entered in the MR by ED Case Management during the time frame Patient A was in the ED. At 1800 RN #2 documented that restraints were discontinued and Patient A was cooperative with care. Documentation by Physician #1 (not specifically timed) indicated patient improved, restraints removed. At 1818, RN #3 documented that the patient was alert, oriented and responded to verbal stimuli and cooperative. At 1830, Physician #1 ordered a CT Scan Head without intravenous (IV) contrast; clinical indication of trauma and confusion, which was obtained at 1855 and showed a 7 mm area of high density in the left cerebellar hemisphere white matter and no evidence for acute intracerebral or extracerebral hemorrhage, mass effect or shift. Physician #1 checked "Medical clearance for psychiatric referral" on the form and indicated a social worker (Licensed Clinical Social Worker / LCSW #1) would see patient in the ED. At 1930, Physician #1 indicated he/she had discussion with LCSW #1, mother and patient; patient back to normal; no suicidal ideation, no homicidal ideation. Physician #1 documented the clinical impression as follows: anxiety, psychosis (resolved) substance abuse and rule-out intracranial bleed. He/she also noted the patient was discharged to home at 1950 (on 1/6/15) in stable condition. On 1/7/15 at 1132, in a late entry documented in the Discharge Planning Progress Note section of the EMR, LCSW #1 entered "Per doctor request met with pt who was calm and cooperative although a bit paranoid. Asked if I could speak with ... mother and if pt wanted to see her. Pt agreed. Pt's mother reports pt has a history of ADHD (Attention Deficit Hyperactivity Disorder) but had outgrown it. Mother reports no other psychiatric issue ... When mother was asked if she knew of any drug use by pt she responded only marijuana. Pt's UDS (urine drug screen) positive for THC. When mother brought to pt's room pt remained calm and cooperative, appeared to have a positive relationship as she gave him a hug and kiss. Pt denied being homicidal or suicidal and mother agreed that she does not believe pt is a danger to himself or others. Discussed treatment options with pt's mother. Mother thought it would be best for pt to return home, when medically cleared, and access outpatient treatment. Discharge plan discussed with Dr. ... (Physician #1) if pt is not admitted then social work will follow up with outpatient referral during next business day. " -- The hospital's policy and procedure (P&P) titled "Social Work Services in the emergency room ," developed 4/2014, addresses referrals to Social Work for psychiatric assessments of children and adults. It notes the ED physician will evaluate patient's medical acuity and once determined medically stable, will write order for MHA in the MR for social work referral. It also noted ED physician to refer to psychiatrist if recommended and that the LCSW completes MHA documentation and transfer documentation as appropriate. --Per interview with LCSW #1 on 1/8/15 at 1350, he/she performs MHAs on patients that are in the ED when the ED physician tells him/her that the patient needs a MHA and/or places an order in the electronic medical record for MHA. After seeing patient for MHA, he/she documents the assessment in the MR and discusses the results with the ED physician, making recommendations regarding the patient. Physician #1 asked him/her to see Patient A. LCSW #1 did not complete a MHA for Patient A on 1/6/15 because the patient had not been medically cleared, a CT Scan Head had been ordered. LCSW #1 thought that Patient A "might be" admitted to the hospital. LCSW #1 was not aware at the time of Patient A's ED presentation that he had been transported to the ED on a 9.41 legal status or that documentation on the 9.41 form indicated report of abuse of animals. --Per interview with Physician #1 on 1/8/15 at 1530, he/she went in to see Patient A shortly after arrival to the ED and could not get much history as the patient would not comment and looked dazed. After Patient A's mother arrived, the patient improved and Physician #1 was able to talk "quite well" with the patient. Patient A denied suicidal and homicidal ideations. Physician #1's usual process is to try and get an MHA with the ED social worker when a patient comes in as 9.41 status. Physician #1 was not aware that the LCSW in this case had not performed an MHA of Patient A at the time of the ED visit. Regardless, he/she did his/her own MHA of Patient A. There were no red flags. Physician #1 spoke with LCSW #1 who reported the patient was fine, stable with no suicidal or homicidal ideation and mom was okay with taking him home. Physician #1 was aware that Patient A was bought in as 9.41 status but was not aware that documentation on the form indicated there was a report that Patient A had abused animals. --Per interview with Physician #1 on 1/12/15 at 1130, he/she normally consults the case manager (LCSW) for MHAs and discharge planning. Patients seen in the ED for psychiatric symptoms have medical clearance performed and the social worker does the MHA. Physician #1 stated he/she cannot review the MHA documented by social work in the EMR because it is in another part of the EMR. He/she reads the free text note entered in the EMR by social work instead. During this interview, in contrast to the interview on 1/8/15 at 1530, Physician #1 indicated he/she was aware of 9.41 documentation that Patient A abused animals, but did not know what the abuse entailed. --Per interview with Physician #2 (another ED attending physician) on 1/12/15 at 1510, MHAs are ordered in the EMR by the ED physician. He demonstrated how to enter an order specifically for a MHA and how to access and view a completed MHA by the social worker in the EMR. SUMMARY: - Information on the Law Enforcement Request for Examination form and the EMS care report indicating the patient was reported to have been abusing animals was not incorporated into and/or explored in the nursing, physician or social worker evaluations of the patient. A complete MHA was not performed. As a result, a complete MSE also was not performed. - Physician #1 was not aware of how to specifically order a MHA by a social worker and thought this was accomplished when he/she selected "Consult case management for mental health- discharge planning" in the orders section of the EMR. - Physician # 1 was not aware LCSW #1 had not completed a MHA.

Based on findings from observation, interview and document review, the hospital failed to maintain an accurate central log for patients observed entering the emergency department (ED). Specifically, for 2 out of 2 patients observed entering the ED the Central Log for the ED lacked accurate information regarding the time of presentation to the ED. Findings include: -- The hospital policy and procedure (P&P) titled "Emergency Department Patient Registration Process," dated 9/15/14, indicates the ED Liaison "Greets the patient and t-registers the patient into the AS400 system". The P&P lacks direction regarding capturing the real time presentation. -- Observed Patient S presenting to the ED on 1/8/15 at 1020. The patient was directed by Security Guard #1 to the waiting room. Security Guard #1 wrote down the patient's first name and time he/she presented to the ED. At 1025 Patient S was called for pre registration. Patient S's medical record (MR) and the ED Central Log indicated Patient S's arrival time was 1025, not 1020. -- Observed Patient T presenting to the ED on 1/8/15 at 1020. The patient and his/her parent were waiting for the other parent to interpret. At 1024 the patient and his/her parents were directed by Security Guard #1 to the waiting room. Security Guard #1 wrote down the patient's first name and the time he/she presented to ED as 1024. At 1030, Patient T and parents were called for pre registration. Patient T's MR and the ED Central Log indicated Patient T's arrival time was 1030, not 1020. -- Interview with Security Guard #1 on 1/8/15 at 1035 revealed he/she writes down the time when the patient passes through the locked door, with an identifier, e.g. first name, initials, reason for coming, and directs them to go to the waiting room. The patient is then called by the ED Liason who then pre-registers them. The Security Guard disposes the piece of paper which has the times the patient presents to the ED. -- Interview with the ED Liason on 1/8/15 at 1040 revealed he/she documents the time of arrival/presentation as the time the pre-registration takes place. The ED Liason does not check with the Security Guard to ascertain the actual time the patient presents. The ED Liason's arrival time is transmitted to the ED Central Log electronically. -- The above findings were discussed with the Chief Nursing Officer on 1/8/15 at 1045.

Based on findings from document review, medical record (MR) review, and interview, the facility failed to ensure emergency department (ED) services were provided in accordance with generally accepted standards. Specifically: (1) ED providers did not ensure completion of a mental health assessment (MHA) for 3 of 8 patients who presented with signs of possible psychiatric conditions (Patients A, D and E). An attending ED physician was not aware of the correct procedure for ordering a MHA by a social worker (Patient A); (2) Nursing did not document complete suicide risk assessments for 6 out of 8 patients who presented to the ED with suicidal ideations and/or attempts (Patients A, C, D, E, F and G). A policy and procedure (P&P) addressing the nursing suicide risk assessment being used in the ED was lacking; (3) Potential patient problems warranting attention were not all addressed or followed up (e.g., alcohol ingestion and/or substance abuse, low potassium) in 3 of 8 MRs reviewed (Patients E, F, and G); (4) The Emergency Provider Records were illegible, incomplete or lacking in 6 out of 8 MRs reviewed (Patients A, C, D, E, F and G); (5) The ED lacked a policy and procedure (P&P) describing assessment criteria for suicidal and homicidal risks. Criteria for homicidal risk assessments were described on an inpatient nursing assessment form but were not defined in the outpatient ED forms. (6) The ED exam rooms used for potential mental health patients were not safe for individuals with suicidal, psychotic or self-injurious behaviors. Specifically, the room contained 2 potential ligature hazards - See findings in Tag A 142; (7) The facility did not provide appropriate post exposure prophylaxis (PEP) to a patient who had been sexually assaulted. Further, the facility P&P did not address the latest New York State Department of Health guidelines regarding PEP for a sexual assault victim - See findings in Tag A 1104. Findings include: -- New York State Mental Hygiene Law, Section 9.41, addresses emergency psychiatric admissions for immediate observation, care, and treatment. It directs that any peace officer, when acting pursuant to his or her special duties, or police officer who is a member of the state police or of an authorized police department or force or of a sheriff's department, may take into custody any person who appears to be mentally ill and is conducting himself or herself in a manner which is likely to result in serious harm to the person or others. It notes that such officer may direct the removal of such person or remove him or her to a hospital or comprehensive psychiatric emergency program (CPEP). -- A form titled "EMERGENCY or C.P.E.P.** EMERGENCY ADMISSION (Sections 9.41, 9.45, 9.55 and 9.57 Mental Hygiene Law)," dated 12/2009, is completed by a peace officer / police officer when section 9.41 of the form is used. Hereafter in this document the form will be referred to as the 9.41 form. -- Review of Patient A's MR reveals the following: He (MDS) dated [DATE], accompanied by local police department staff (LPD) and in handcuffs. Documentation on the 9.41 form and the Law Enforcement Request for Examination form listed the following for description of Patient A: alleged animal abuse, hostile, belligerent, overly suspicious, feelings of persecution, confused and disoriented, hearing voices, a danger to him/herself and/or others. The electronic medical record (EMR) contains an order for "Consult Case Management ED Referral Needs: Discharge Planning." (Per interview of Physician #1 on 1/12/15 at 1130, this is what he/she selects in the EMR when intending to order a MHA. Per interview of Licensed Clinical Social Worker (LCSW) #2 on 1/12/15 at 1230, the correct selection for ordering a MHA is "Consult Case Management ED- Mental Health." The physician then enters via a free text under "Referral Needs" - "Mental Health Eval"). A free text late entry by LCSW #1, dated 1/7/15 and timed 1132, indicates he/she "...met with the patient per Physician request. Patient is calm and cooperative.....Discussed with the ED physician...if not admitted then will follow up with outpatient referral next business day." This documentation did not constitute a MHA - the MR lacked documentation of a MHA. -- During interview with LCSW #1 on 1/8/15 at 1320, he/she stated that he/she did not complete a MHA for Patient A. Nursing documentation on the "Suicide/Safety Evaluation" section of the EMR only addresses 1 out of 11 questions regarding the patient's risk factors for suicide risk (male gender) and lacks a suicide risk score (due to the 10 questions not answered). Approximately 3/4 of the documentation on the Emergency Provider Record was illegible, requiring deciphering by Physician #1 during interview on 1/8/15 at 1530. -- Review of Patient C's MR reveals the following: He (MDS) dated [DATE], self-referral with suicidal/homicidal ideation. The patient was admitted . The nursing "Suicide/Safety Evaluation "section of the EMR was blank. Approximately 3/4 of the documentation on the Emergency Provider Record is illegible. -- Review of Patient D's MR reveals the following: She presented to the ED via private vehicle accompanied by her parents. The middle school she attended sent her to have a mental health evaluation due to cutting herself on upper thighs. The patient was transferred to an adolescent mental health facility. The MR lacked documentation of a MHA. The nursing "Suicide/Safety Evaluation" section of the EMR was incomplete, 4 out of 11 questions were not answered and a suicide risk score is lacking. Approximately 2/3 of the documentation on the Emergency Provider Record is illegible. -- Review of Patient E's MR reveals the following: He (MDS) dated [DATE], accompanied by the LPD. Documentation on the 9.41 and the Law Enforcement Request for Examination form indicated overdose of Xanax medication. The MR lacked an Emergency Provider Record (the ED physician's patient assessment, treatment and diagnosis form), documentation of a MHA, and discharge instructions. The nursing "Suicide/Safety Evaluation" section of the EMR was blank. Laboratory test results in the EMR indicate the patient's potassium level was decreased (2.9 with the normal range being 3.5-5.3). The patient received potassium chloride 20 meq/15 ml orally and potassium chloride 20 meq ER (extended release) tab orally. There is no evidence the low potassium was followed up during the ED visit and/or arrangements for outpatient follow up were made. -- Review of Patient F's MR reveals the following: He (MDS) dated [DATE], via the LPD. Documentation on the 9.41 form and the Law Enforcement Request for Examination indicated the patient placed himself in dangerous situations, made verbal threats of harm to self, and there was presence of weapons/danger. Nursing documentation revealed the patient was drinking and upset at home about an incident, and walked into the garage with weapon threatening to kill himself. The patient was admitted . The nursing "Suicide/Safety Evaluation" section of the EMR was incomplete, 8 out of 11 questions were not answered and a suicide risk score is lacking. An alcohol abuse assessment is not documented. Also, while an ethanol level was ordered and returned with a result of 204 (normal being 0-10), the documentation on the Emergency Provider Record lacks indication (in an area provided) that the patient had ingested alcohol. Approximately 90% of the documentation on the Emergency Provider Record is illegible. -- Review of Patient G's MR reveals the following: He (MDS) dated [DATE] via ambulance due to overdose/suicidal ideation. He had taken a handful of sleeping pills along with 40 ounces of beer in hopes of harming himself. The nursing "Suicide/Safety Evaluation" section of the EMR was incomplete, 8 out of 11 questions were not answered and a suicide risk score is lacking. While an ethanol level was ordered and returned with a result of 13 (normal being 0-10), the documentation on the Emergency Provider Record lacks indication (in an area provided) that the patient had ingested alcohol. An alcohol abuse assessment is not documented. The suicide risk assessment on the Emergency Provider Record does not contain the clinician's estimation of suicide risk, the progress and interventions section of the form are blank. The patient was admitted and the disposition time is illegible. -- During interview with the Medical Director on 1/12/15 at 1530, ED physician illegibility and incomplete documentation were acknowledged and discussed, respectively. Findings specifically regarding (5) above on page 3 include: -- Review of the EMR Print Screen titled "Suicide Risk Assessment - ED," reveals the assessment requires nursing to address 11 questions. The EMR then calculates the Risk Score based on the answers selected by nursing. A second Print Screen titled "Suicide Risk Assessment - Inpatient" was presented by Director of Risk Management on 1/9/15 at 1350. This screen also contained a "Homicidal Risk Screen" with 2 questions - these questions are not part of the physician or nursing homicidal assessments completed in the ED. Per interview with the Director of Risk Management on 1/9/15 at 1350, he/she stated that the facility did not have a written P&P for Suicidal and/or Homicidal Assessments.

Based on findings from document review and interview, the facility did not provide appropriate post exposure prophylaxis (PEP) to a patient who had been sexually assaulted. Further, the facility policy and procedure (P&P) did not address the latest New York State Department of Health guidelines regarding PEP for a sexual assault victim. Findings include: -- Review of Patient K 's medical record (MR) revealed the patient arrived at the emergency department (ED) at 2120 with a chief complaint of sexual assault. The physician orders include Azithromycin 250 mg 4 tabs, ciproflozacin 500 mg, Flagyl 500 mg and levorgesterl 0.75 mg which were all administered orally to the patient. The discharge orders did not include providing the patient with a seven (7) day starter pack of HIV PEP and arrangement of an appointment for medical follow-up related to HIV PEP (as required by New York State Public Health Law, Chapter 39, Section 1, Paragraph c of subdivision 1 of section 2805-i, effective November 27, 2012.) -- Review of the facility P&P titled "Care of the Patient with Sexual Assault," dated 9/2007, revealed it does not require hospital staff to provide a victim of sexual assault with a seven (7) day starter pack of HIV PEP and to arrange for an appointment for medical follow-up related to HIV PEP . -- During interview with the Vice President of Quality Management on 1/09/15 at 1420, the above findings were discussed.