Based on medical record review, document review and interview, in one (1) of eight (8) medical records reviewed, it was determined the facility failed to ensure that staff conducted a behavioral health screen for a patient who presented to the Emergency Department (ED) with psychiatric crisis. This was evident for Patient #1. Findings include: Review of medical record for Patient #1 identified: Patient arrived by ambulance to the Emergency Department (ED) on 7/26/18 at 12:43 AM with altered mental state. Triage was conducted at 12:46 AM and a medical screening examination was conducted at 12:58 AM. Information obtained from contact with the patient's husband reported patient signed out of another psychiatric facility the previous day where she had been admitted for Depression on 7/12/18. The the patient was confused and was singing and walking around in the home naked in front of her teenage children and that she was refusing to take her medications. Due to the acute nature of the available information from the patient's prior medical record, the patient was placed on continuous observation by the physician. At 1:10 PM, the physician noted patient initially refusing to allow blood draw but was otherwise calm. Ongoing treatment included supportive care. Second reassessment the patient noted, "patient is uncooperative with staff, bothering other patient and not abiding by simple requests to stop going into other patient areas. Patient becoming increasingly aggressive towards staff." Haldol 5mg and Ativan 2mg intramuscularly (medications for agitation) was ordered and administered by nursing staff them at 3:17 AM. At 6:45 AM, the ED doctor reassessed the patient and noted she was asleep and in no distress, and at approximately 6:49 AM the patient was endorsed to the Physician Assistant (PA) and another ED doctor. The initial encounter physician's diagnosis: Acute Psychosis and Bipolar Disorder. The accepting ED doctor documented that he reassessed the patient which revealed the patient was sleeping but easily awoken. "Patient states she was doing okay and was encouraged to eat the food at bedside. Waiting to be seen by psychiatric social worker." This provider's next entry noted the patient was psychiatrically cleared for discharge by psychiatric social worker working with the psychiatrist. A Licensed Masters Social Worker (LMSW) documented an "Initial Screening Progress Note" at 10:13 AM, noting: ....Patient states "had a 'manic attack last night and started pacing. Patient said her thoughts mostly revolved around missing the Brooklyn area, where she used to live before coming to to Rockland County three (3) years ago. Patient is alert and oriented x 4, and presents with a clear and organized thought process. Patient denies SI/HI. Patient is requesting to go home." Collateral information was obtained from contacting patient's husband. The LMSW wrote that the clinical information was reviewed with the psychiatrist. Patient did not present with any acute psychiatric symptoms that would require an admission at this time. It is recommended that patient seek treatment at another academic institution that can offer intensive treatment for rapid cycling bipolar. Documentation on the Nursing Assessment & Progress Notes states, patient was discharged from the ED 7/26/2018, at 9:56 AM. The patient was taken back to the ED the next day, 7/27/18 because she "continued to display bizarre behaviors in the home." She was admitted to the Behavioral Health Unit that day with a diagnosis of Bipolar Disorder. Review of the policy titled "Emergency Department-Psychiatric Assessment & Referral," which is not dated, states: "the triage nurse will notify the designated Qualified Mental Health Professional on call to perform a behavioral health screening for patients who present with psychiatric crisis." The document, "Behavioral Health Initial Screening and Assessment" consists of eight (8) pages. There is no documented evidence that the Qualified Mental Health Professional completed this assessment. During interview on 10/5/18 at 9:35 AM, the Licensed Masters Social Worker, acknowledged that she had not conducted the behavioral health screening and assessment but that she had only documented an initial screening progress note. Staff B confirmed that she had not read the ED nurses and physicians notes and that she was unaware of the patient's behavior which required Haldol and Ativan administration at 3:17 AM that morning. Staff C, Psychiatrist who approved the patient's discharge on 7/26/18, stated during an interview conducted on 10/4/18 at 12:25 PM, that he did not examine or see the patient but that he had done a phone consultation for this patient. Staff C stated he was unaware of the patient's behavior at 3:00 AM that morning that warranted the administration of the medications. These findings were shared with Staff A, the Interim Director of Quality, the CEO and Medical Director at approximately 2:00 PM on 10/5/18.

Based on record review, document review and interview, in one (1) of 12 medical records reviewed, it was determined the facility did not ensure that each patient that presented to the Emergency Department (ED) with a complaint of chest pain was appropriately classified and lab specimens completed in a timely manner. (Patients #1) Findings include: Review of medical record for Patient #1 revealed the following: This [AGE] year old patient (MDS) dated [DATE] at 1:35 PM with a complaint of chest pain. According to the ambulance care report the patient stated that the previous day she started to have some discomfort in her chest but today the pain got worse. The pain was rated at 10, (on a numeric scale of 0 no pain, to 10, the most severe pain). The pain radiated to her jaw and left arm from the center of her chest. She told the crew that in 2014 she had a heart attack which resulted in a cardiac arrest. EMS gave the patient 3 Aspirin tablets with a dosage of 81 mgs each and transported her to this ED at 1:33 PM. According to the medical record an electrocardiogram (EKG) which was done at 1:40 PM revealed abnormal finding. The patient was triaged at 1:46 PM and she was assessed as pale but non-diaphoretic; her pain score was rated at 6/10, the pain was described as pressure-like and patient verbalized having an MI (Myocardial Infarction - heart attack) in the past year. The patient was assigned an Emergency Severity Index (ESI) Level of 3 - Urgent. This patient was assigned an ESI Level - Urgent and not an ESI level 2, which required immediate care. The facility policy titled "Emergency Department Triage: Patient Management," last revised 10/15 indicates an ESI Level 2 (Emergent) for "high risk situation, severe pain/distress, or acute confusion, lethargy, or disorientation." Labs were drawn at 1:49 PM for cardiac enzymes (Troponin I) but the orders were written at 2:45, and there was no documentation that the specimens were sent to the lab. Another specimen was collected at 4:23 PM and it was resulted at 4:49 PM, more than 3 hours after the patient's arrival. The patient was admitted to the Rapid Diagnostic Unit at 6:59 PM for the repeat cardiac enzyme. Another specimen for Troponin I was resulted at 7:46 PM which revealed the level had increased to 1.5 ng/mil (a positive test which is indicative of a Myocardial Infarction). The patient was diagnosed with a Non S-T segment Elevated Myocardial Infarction (NSTEMI), medication treatment was started at 9:39 PM and the patient was transferred to another acute care hospital at 10:09 PM that night. During an interview which was conducted at 10:15 AM on August 5, 2016, Staff C, the Charge Nurse on 6/7/16, stated that after some time had elapsed after the labs were drawn at 1:49 PM, the patient's ED physician enquired about the Troponin results. When an investigation was undertaken it was determined that the nurse assigned to the patient, had drawn the blood samples at 1:49 PM, but she had not labeled or sent the specimens to the laboratory. The specimens were found at the bedside and discarded. Staff failed to ensure that the lab testing to rule out the diagnosis of NSTEMI was completed in a timely manner. These findings were shared with the Director of Quality on August 8, 2016 at 3:00 PM.