Based on medical record reviews, staff interviews and policy reviews, it was determined patients did not receive appropriate and timely care based on the type of insurance. This was found in 2 of 29 medical records reviewed. This was found in medical records (patient) #1 and #3. Findings include: 1. There was a delay in providing care to patients who had Affinity Insurance that presented to the Montefiore Mount Vernon Emergency Department (ED). A review of medical record #3 on January 12, 2015 revealed this patient presented on December 18, 2014 at 5:13 AM "yelling and screaming." An ecchymotic area (skin discoloration caused by the seepage of blood into the tissues from rupture blood vessels) was noted on the patient's left outer thigh. The nursing staff noted that the patient had observable signs of mental illness, was feeling anxious, was agitated and that she had dramatic mood changes. The physician documented that the patient was agitated, crying and and that she had a psychotic behavior. There was no documentation that the staff attempted to ascertain the nature of the patient's ecchymotic thigh. A review of the medical record on January 12, 2015 revealed upon arrival the patient was yelling, not following any oral commands, but was "stating mommy tell dad not to do this, he is hurting me." Then the patient removed all her clothing and eloped. The record does not indicate when the patient eloped and when she returned even though she was placed on constant observations upon arrival. The patient's global assessment of functioning (GAF) was 20 [a score within the 11 to 20 range indicates some danger of hurting self or others, or occasionally fails to maintain minimal personal hygiene, or gross impairment in communication // the GAF numeric scale is: 0 inadequate information, 1 to 10 persistent danger of severely hurting self or others, or persistent inability to maintain personal hygiene, up to 91 to 100 no symptoms - superior functioning in a wide range of activities] and she had a previous medical history of Post Traumatic Stress Disorder (PTSD), Psychotic episodes and Cannabis abuse. Further review of the medical record on January 12, 2015 revealed the psychiatric consultation done at 10:31 AM indicated "due to repeated ED visits with unclear interim outpatient treatment of underlying illness, recommend consider an inpatient mental health admission. Patient has Affinity Insurance and cannot be admitted for inpatient mental health to Montefiore Mount Vernon." The patient was later evaluated by the chairman of Psychiatry who approved the patient's discharge from the ED that day at 12:35 PM. 2. A review of medical record #1 on January 12, 2015 revealed this is a twenty-seven year old patient who presented on January 4, 2015 at 11:01 PM with a complaint of hearing voices, poor sleep and depressed appetite for the past 2 days. The patient was worried about her 4 year old daughter who was in the custody of her (daughter's) father. The psychiatrist did not explore the nature of the patient's hallucinations. The patient was discharged from the ED on January 5, 2015 at 12:32 AM. The patient went to a police station and told them she was hearing voices and seeing things. The patient was taken back to the facility that day (January 5, 2015) at 9:12 AM. The triage nurse noted that the patient was not answering questions and that she had observable signs of depression. The patient was combative at times and her global assessment of functioning (GAF) was 15. The patient was thought blocking and her insight and impulse control were poor. A decision was made to admit the patient. Further review of the medical record on January 12, 2015 revealed the patient remained in the ED until January 7, 2015 while awaiting a bed at another facility because her insurance was not in network. Documentation that morning at 11:10 AM revealed the patient's hallucinations had subsided, however, the patient was discharged at 1:10 PM that day. The Chairman of Psychiatry was interviewed on January 13, 2015 at 2:00 PM at which point he stated that patients that have Affinity Insurance are out of network and therefore they cannot be admitted here. The patients did not receive necessary care because the patients health insurance was not part of the facility's insurance network.

Based on medical record reviews and staff interviews, it was determined a patient did not receive an appropriate medical screening examination when he presented to the emergency department (ED). This was found in 1 of 29 medical records reviewed for patient #2. Findings include: This patient did not receive an appropriate medical screening examination prior to his discharge from the ED. A review of patient #2's medical record (MR #2) on January 12, 2015 revealed the patient, who is a welder, presented to the ED at 7:07 AM on Friday, September 26, 2014 with a complaint of eye trauma that had occurred the previous day. The patient's pain level was 9 on a scale of 0 (no pain) to 10 (worst pain imaginable). A telephone eye consultation was done and the patient was discharged from the ED at 8:12 AM that morning for an eye consultation at another location. The record notes the patient was discharged to go to the doctor's office at 202 Steven's Avenue in Mount Vernon. The patient returned to the ED at 9:56 AM that morning where it was noted that the patient had a dislocated lens in the left eye. The patient was transferred to another location where another eye consultation was conducted at 4:00 PM that day. This consultant noted the patient had a displaced lens with vitreous humor coming forward into the anterior chamber and that there was a peripherally shallow anterior chamber with elevated intraocular pressure. Treatment recommendation was to insert Pred Forte 1 drop every 2 hours, Cosopt bis in die (BID = Latin for "twice daily") and Atropine BID. The patient was to follow-up with doctor the following day and Monday. These findings were discussed with the Director of Quality Management on January 12, 2015 at approximately 2:00 PM. The patient's discharge from the hospital at 8:12 AM on September 26, 2014 for an eye consultation at another location was inappropriate given the nature and location of the patient's trauma.

Based on medical records reviews, policy reviews and staff interviews, it was determined the hospital failed to provide emergency care consistent with prevailing standards of practice. Specifically, (1) consultations were not comprehensive and (2) reassessments of patients were not performed. This was found in 9 of 50 medical records that were reviewed. This was found for patients MR #1, MR #2, MR #5, MR #6, MR #15, MR #24, MR #29, MR #38, and MR #41. Findings include: 1. Review of the facility's electronic database on November 21, 2014 revealed patient #1 (MR #1) made 38 visits to the facility from September 2013 - November 19, 2014. The patient was only admitted on 1 occasion to the behavioral health unit since September 2013. There was no documentation found in the medical record that a comprehensive psychiatric consultation was conducted on each of the patient's visits to the emergency department. Review of medical record #1 on November 21, 2014 revealed on the September 30, 2014 Emergency Department (ED) visit, the psychiatrist's evaluation/consultation states "formal mental status exam is not practical as she is severely agitated, screaming, inconsolable and unapproachable. Recommend give Haldol 5 milligrams (mg) intramuscularly for her own safety and release when episode is resolved and refer back to outpatient psychiatrist." A comprehensive psychiatric consultation was not done for this visit. Review of medical record #1 on December 3, 2014 revealed the patient was given Haldol, Ativan and Cogentin at 4:26 PM. The psychiatrist documented at 6:34 PM that the patient had a good response to the medications that were administered and that her "presentation on arrival was not as severely disturbed as on prior visits." The psychiatrist also noted that pending medical clearance the patient may return home with outpatient follow-up appointments. However, the ED physician documented at 8:12 PM that night that the patient was awake and distraught and she was requesting additional medication to calm her. The patient was again given Haldol, Ativan and Cogentin at 8:31 PM that night. There was no documented evidence in the medical record that the patient was re-evaluated by a psychiatrist after the second doses of medications were administered. The patient was discharged approximately 9 hours after she arrived at the facility. Review of another ED visit for patient #1 on December 3, 2014, revealed the emergency medical service (EMS) brought the patient to the ED on November 19, 2014 as an "emotionally disturbed person" at 10:24 AM. According to the psychiatrist note documented at 11:41 AM the patient stated "leave me alone, mommy help me. I'll be a good girl." The psychiatrist also noted at that point that after the usual medications (Haldol, Ativan and Cogentin) were given the patient "calmed down and was able to interact normally with staff while drowsy and without fear of dozing off and that he would re-evaluate the patient when she awakes from her medication induced slumber." The GAF was listed as 25/60. The patient was discharged at 3:15 PM after 3 hours of sleep. A comprehensive psychiatric evaluation was not conducted. Patient #1's other ED visits, also included, but were not limited to a November 23, 2014 ED visit, which revealed the patient did not receive a comprehensive psychiatric evaluation to determine the patient's appearance, behavior, agitation, grooming/hygiene, eye contact, attitude, psychomotor activity, mood, affect, speech/language, thought process and/or thought content. Reviews of medical record #1 on November 21, 2014 revealed the patient returned to this ED on September 30, 2014, October 7, 24 and October 26, 2014, November 9, 12, 19, 23, 2014 and December 18, 2014 with similar complaints and was seen and discharged home after each visit. 2 (a) Reassessments were not conducted prior to the discharge of patients from the ED. During a review of the medical record (#1) on December 3, 2014 it was revealed that at 4:33 PM on November 12, 2014 the patient presented to the ED "crying, scared and verbalizing fear." The patient admitted to seeing scary things but she did not elaborate on her hallucinations. Her mood was depressed and she had impaired insight, judgment and impulse control. The patient was also noted to be cognitively impaired due to her psychotic break and she needed 1:1 observation according to the psychiatrist. This record also indicates the patient had an order of protection against her husband. b. Medical screening examinations were not performed prior to the psychiatric consultations to ensure that all patients were medically cleared for these consultations. According to current standards of practice, a medical screening examination must be conducted prior to a psychiatric consultation. The following finding includes, but is not limited to patient #1. Review of medical record #1 on December 3, 2014 revealed the psychiatrist documented that pending medical clearance the patient may return home with an outpatient follow-up on the November 12, 2014 ED visit. The facility's policy titled "emergency room Psychiatric Evaluation" last revised 5/14 states "the medical evaluation may proceed in concert with the psychiatric evaluation." However, this is not consistent with prevailing standards of practice where all medical conditions and emergencies should be ruled out before psychiatric consultations can be performed. (c) A review of patient #29 (MR #29) on January 8, 2015 at 7:07 AM revealed this is a fifty-three year old patient that presented on September 26, 2014 with a complaint of eye trauma that had occurred the previous day. The patient was alert and oriented and reported a pain level of 9 on a scale of 0 (no pain) to 10 (most severe pain). A telephone eye consultation was done and the patient was discharged from the ED at 8:12 AM that morning for an eye consultation at another location. The patient returned to the ED at 9:56 AM that morning where it was noted that the patient had a dislocated lens in the left eye. The patient was transferred to another offsite location at 1:30 PM that day for further management. The patient's discharge from the hospital at 8:12 AM for an eye consultation at another location was inappropriate given the nature and location of the patient's trauma. (d) A review of medical record #38 on January 7, 2015 revealed this twenty-two year old patient presented on April 12, 2014 at 7:50 PM with complaints of nausea, vomiting and abdominal cramping. The patient also reported diarrhea and that he was not eating. The physician noted that the patient had bilious coffee ground vomitus for 1 day which was of sudden onset. The patient was anxious and grimacing, but there was no documentation of a pain score. According to the physician the patient did not have pain. The physician's notes did not indicate the time that the patient was seen. The physician noted that the patient reported that the patient stated that this was his second episode, but the physician did not identify any precipitating factors, frequency of this episode and what specific location (quadrant) that the patient had the pain. Review of the electronic database revealed the patient had 4 prior episodes of these symptoms and that he was admitted in April 24, 2013 where he had undergone an EGD (esophagogastroduodenoscopy) which revealed the patient had a Mallory Weiss Tear, Gastritis and Reflux. The physician's review of the patient's abdomen revealed there was no abdominal pain which was inaccurate. The patient was given intravenous fluids, Zofran and Esomeprazole intravenously. A review of the medical record on January 7, 2015 revealed the nurse's notes documented at 9:53 PM revealed the patient had tenderness in the epigastric area and that the nausea and vomiting had not resolved. The physician's recheck notes indicated the patient was improving with treatment and that he was stable. The patient was discharged at 1:44 AM on April 13, 2014 without the benefit of a gastrology or surgical consultation and there was no documentation that the patient's pain score was evaluated throughout his visit. (e) Review of medical record #5 on January 7, 2015 revealed this is a thirty-five year old patient who presented on January 1, 2015 at 1:13 AM with a complaint of vaginal bleeding and vaginal cramps. The patient was 8 weeks pregnant. There was no documentation in the medical record of the patient's pain score. She was discharged at 3:43 AM that morning with a diagnosis of threatened abortion without any physician or nursing documentation of the patient's level of pain during her ED stay. The facility's policy titled "Pain Management" last revised 12/14 states "The Numerical Rating Scale (0= no pain to 10= worst pain imaginable) should be the first scale utilized." (f) A review of medical record #15 on January 9, 2015 revealed this patient presented on December 2, 2014 at 3:38 PM for an evaluation of a syncopal episode. The patient reported shortness of breath after walking up 2 flight of stairs then he got dizzy and passed out. The patient was given oxygen and intravenous fluids prior to arrival in the ED. The patient's previous medical history included Deep Vein Thrombosis and Diabetes Mellitus. Diagnostic tests results were consistent with severe cardiac ischemia. At 4:40 PM the Blood Pressure (B/P) was 146/106, at 6:09 PM it was 140/100, and at 8:27 PM it was 142/101. There was no documentation in the medical record that a physician was notified of these elevated blood pressure readings. The next B/P check was conducted at 6:00 AM on December 3, 2014 when it was still elevated at 134/89. This 10 hour gap between the 8:27 PM and 6:00 AM B/P assessments were not consistent with the facility's policy and current standard of practice. A review of the policy title "Vital Signs Monitoring" which was last revised 2/14 states blood pressures should be taken at least every four hours if the blood pressure is unstable. The patient's blood pressure was elevated, therefore, it should have been rechecked in a more timely manner in keeping with this policy.