Based on medical record review, document review and staff interview, it was determined that the facility failed to follow its policy for the care of patients that presented with a complaint of sexual assault and failed to document the disposition of forensic evidence. This finding was evident in one (1) of seven (7) medical records reviewed. (Patient #5). Findings include: Review of the medical record for Patient #5 revealed this sixteen year old patient presented to the emergency department (ED) on February 22, 2016 at 11:38 AM with a complaint of "unplanned sexual encounter." The patient was examined by a provider but there was no documented account of the assault. The patient was alert and oriented, nervous and anxious. The patient's pain score was 4 on a scale of "0" no pain to "10" the most severe pain, but there was no documentation of the location, onset or pattern of the pain. There was no documented evidence that the Sexual Assault Forensic Examiner (SAE) arrived and/or that the sexual assault forensic examination was provided as per facility's policy for provision of care for sexual assault victims. The facility's policy titled "Patient Abuse: Sexual Assault Victims: Adult, and Patient," last reviewed 1/16, states: "When a patient presents to the Emergency Department and indicates that she/he has been a victim of sexual assault, the triage nurse will immediately notify the Charge Nurse. The patient (victim)...will have the services of the Rape Crisis Program advocate and the Sexual Assault Examiner explained and offered." The policy states the process for initiating contact with the Rape Crisis Victim Advocate and the protocol for the sexual assault forensic examination. The facility's staff could not report the location or disposition of the kit and forensic evidence, which is not in compliance with the facility's sexual assault policy. The policy also states "The ORMC Healthcare Team will be respectful in their communication with and treatment of victims of rape and sexual assault, maintaining sensitivity to the trauma that such patients have experienced. The healthcare team will allow time to listen to and acknowledge the rape or sexual assault victim's feelings of anxiety, depression, pain and helplessness." There was no documented evidence in the facility's medical record that this policy was followed as there was no documentation that the incident was discussed or that the patient's emotional needs were addressed. The findings which were identified in the medical record were shared with Staff B, the Information Technologist during an interview on March 21, 2016 at 2:30 PM. Review of the medical record for Patient #1 identified; patient presented on January 18, 2016 at 8:48 PM with a complaint of sexual assault that day at 6:00 PM, after she had just met the assailant. The advocate and SAE nurse who are contracted employees, provided care to the patient. A medical screening examination and complete work-up was done which included pregnancy test, hepatitis function panel, HIV and a urine culture. The police was present and evidence, which included a rape kit, was collected but there was no documentation of the disposition of the kit. The facility's staff could not report the location or disposition of the kit and forensic evidence. This is not in compliance with the sexual assault policy which states "all specimens will be handed over to the police officer in the Emergency Department" or "stored in a locked and secure area in the SAE room for a period up to 60 days." The policy also sates the ED nurse will maintain the chain of evidence for all specimens: the police officer will sign the "Transfer of Evidence to Police" form and the "chain of evidence flow sheet" will be secured along with the specimens collected. The findings which were identified in the medical record were shared with Staff B, the Information Technologist during an interview on March 21, 2016 at 2:30 PM.

Based on medical record review and interview, the hospital failed to ensure that patients are appropriately transferred. This finding was evident in one (1) of 10 medical records reviewed(Patient #1). Findings include: Review of the medical record for Patient #1 identified: This [AGE] year old male with a psychiatric disorder, who was brought to the Hospitals' Emergency department on 1/13/16 at 9:47 PM, by Mobile Life Support Services (EMS). The Hospital refused to accept the patient and advised the Mobile Life Support Team to take the patient to another hospital. There is documentation in the medical record that the other hospital did not agree to the transfer. The facility sent the patient to the recipient hospital without an accepting provider at the recipient hospital. In addition, there is no documented evidence that the facility provided the required documentation for the transfer to the recipient hospital. As per documentation in the patient's medical record, on 1/27/16 at 10:14 PM, a Psychiatrist in the Emergency Department wrote a late entry for 1/13/16. He documented that the patient "will be transferred to another hospital by the police. It took a while to get the transfer because the {accepting} hospital put up with resistance and they talked back and forth between security and finally the police transferred the patient there." During an interview on 2/10/16 at 2:20 PM, the Medical Director for Emergency Services (Staff #3), stated that on 1/13/16, he was advised by The Clinical Supervisor for emergency room that he is not to treat the patient. The patient is to be sent to another hospital for care. He said he took to patient's vital signs to ensure that the patient was "stable" for the transfer. He also stated that the patient was in handcuff and was "not threatening." He called the receiving Hospital and spoke with an emergency room Physician regarding the transfer. The Physician did not agree to the transfer. The patient was taken to that same hospital by the police and EMS; however, there was no written information or transfer package sent with the patient.

Based on medical record review, document review and staff interview, there was no evidence that patients received complete or adequate medical screening exams. This finding was evident in one (1) of 10 medical records reviewed.(Patient #1) Findings include: Review of the medical record for Patient #1 revealed: this [AGE] year old male with a history of Bio-Polar disorder has been on medication for more than 2 years. On 1/13/16, patient was assessed and brought to the facility by the mobile crisis unit; the report documented patient was "combative and agitated" and patient agreed to be transported to the facility. Upon arrival at the hospital Emergency Department on 1/13/16 at 9:46 PM, the Mobile Life Support Services team was met by two Security Officers from the hospital. The patient was escorted into the Behavioral Health Unit. While in the Behavioral Unit the Mobile Life Support staff was told by a Registered Nurse (Staff #1) that "the patient was not allowed to be treated at the hospital, and that he had "threatened to harm multiple staff." Registered Nurse (Staff #2), refused to sign for Hospital acceptance of the patient. The Mobile Life Support Services team documented: " Due to patient being restraint, and unable to sign and due to the hospital refusing to sign for patient, and facility acceptance, Mobile life unit crew signed. "The patient was transported to another Hospital for care." At 10:15 PM, Staff #2 documented: "Patient was seen here the other day and a note was left for security and charge nurses that if patient arrives security needs to be notified. Patient had made multiple threats to various hospital personnel. Upon arrival patient is not cooperating and making threats to staff Per security officer. Patient is not allowed to be seen here, he must go to another facility. Nursing Supervisor made aware. Security informed Charge RN that he spoke with the Director of security, who spoke to (COO) Chief Operating Officer, patient is to be sent elsewhere." There is no documentation in the medical record that the hospital triaged the patient. At 11:31, PM Medical Director for the Emergency Department (Staff #3) documented that he examined the patient. "He is agitated but speaking in complete sentences. The patient's lungs was clear, his heart normal and his abdomen was non tender and soft, told by the Clinical Supervisor RN, that as per our COO and Chief of Security, we are not to care for the patient". The Medical Director documented that the patient needs to be cared for at another facility. The physician wrote that on 1/13/16, he observed the patient and that his mood was "angry". Affect was labile, speech was pressured, coherent but illogical. He was delusional, making threats. His speech was gibberish. He was impulsive, unpredictable and his memory was fair. Insight and judgement was poor. The PLAN: "The patient needs to be admitted in another psychiatric facility this time as the patient remained aggressive and dangerous to self and others." At 11:47 PM, Staff #2 (RN) documented that the patient left the hospital with Town Police. On 1/27/16, (Staff #4) a Psychiatrist in the emergency department documented a late entry for the event of 1/13/16. No time was entered for 1/13/16. This psychiatrist documented that the patient came in handcuff and was "very agitated and was making threat to hurt people." He ordered Haldol and Ativan IM, but did not know that patient should not be treated at the hospital, as a result the patient was never administered the medication. The patient was transferred. The facility initiated an assessment but there is no documentation of a complete or adequate medical screening examination. During interview on 2/10/16 at 1:35 PM, the Chief Operating Officer and Director of Security were both present. The COO stated that on 1/13/16, he received a telephone call from the Emergency Department advising him that patient was present. He called the Director of Security and told him to instruct the emergency room staff not to treat the patient, and to send the patient to another hospital. His decision was based on a phone call from the patient to the hospital on [DATE], where he made verbal threats to members of the hospital board. The Director of Hospital Security confirmed that he received a telephone call from the Chief Operating Officer on 1/13/16, instructing him not to have the emergency staff treat the patient and to send him to another hospital for treatment. The Director of Hospital Security said he gave these instructions to the Security Officers assigned to the emergency room and the emergency room Nursing Supervisors. During interview on 2/10/16 at 2:20 PM The Medical Director for Emergency Services (Staff #3) stated that on 1/13/16, he was advised by The Clinical Supervisor for emergency room that he is not to treat the patient. The patient is to be sent to another hospital for care. He said he took the patient's vital signs to ensure that the patient was "stable" for the transfer. During interview on 2/10/16 3:30 PM, The Director of Accreditation and Regulatory Affairs (Staff #5) acknowledged that the patient was denied care by the Hospital. When asked whether or not this was due to a shortage of psychiatric beds she said no. The inpatient psychiatric unit has 30 beds and 3 in the emergency department. Both areas had available beds on 1/13/16.

Based on document review and staff interview, in 5 of 10 medical records (MR) reviewed, it was determined that the facility did not follow its policies to ensure that all patients who presented to the emergency department; (a) are assessed in a timely manner, (b) treatments are initiated in a timely manner and (c) consultations are done as required (MRs # 1, 2, 5, 7 and 8). Findings include: (1) Review of MR #7 revealed this fifty-seven year old patient presented on July 8, 2015, at 10:12 AM, after he had collapsed while he was walking that morning. The documentation by the triage nurse states the patient was getting ready to jog when he became dizzy and collapsed. EMS was nearby and attended to the patient. The "patient became anxious in the ambulance pulling out IV access and becoming SOB" (short of breath). The documentation by the ED physician states, the patient arrived to the ED " talking with EMS and providers and nursing staff. When the patient was brought to the room however, he had a seizure." After the seizure activity the patient's heart rate went from 60 to 0. The patient did not have a history of Seizure Disorder, but he had pre-existing medical history that included Gastric Bypass in May 2015, Cancer of the Prostate, Embolism and Thrombosis and Asthma. It could not be determined the time that the patient's heart rate was 60 and the time that it decreased to 0. The medical record does not indicate the duration of the seizure activity, specifically when the seizure began and ended, as required with current standards of practice for documenting seizure activity. Documentation by the nurse states, while the patient was in the hallway the patient began to have a seizure. The nurse documented that the patient was " hooked up to a monitor and began agonal breathing and the pulse began to slow." The patient developed asystole at 10:22 AM and he had agonal breathing. Chest compressions and resuscitative measures were initiated at this point. The patient expired at 10:42 AM that morning. The documentation in the medical record identified that during the period of 10:12:45 to 10:17 AM; the patient was moved from room #12 which is a non-monitored bed, to the hallway, then returned to room #12, and at 10:24 AM, was transferred to room #16, which is a monitored bed. There is no documentation to validate the monitoring that was provided to the patient during this period, prior to the patient being "hooked up to a monitor and began agonal breathing and the pulse began to slow." (2) Review of MR #1 revealed this is twenty year old patient presented to the ED at 6:52 PM on September 2, 2015, after he had fallen in his bathroom and had an episode of loss of consciousness. Patient's sister states, she heard a "lot of banging and crashing" and when she tried to open the bathroom door it was blocked with the patient's body. After the patient woke up he felt weak, lethargic, was confused and vomited. The EMS report states the patient's B/P 88/60 and he had excessive diaphoresis, was very lethargic and had an ashen color; EMS initiated oxygen treatment and intravenous fluids. The patient had a history of Bipolar Disorder and Depression. The physician's review of systems revealed the patient had mild scalp [DIAGNOSES REDACTED]; history of fatigue, seizure and weakness. The "Morse Fall Risk " assessment for this patient was incomplete and only one question was answered; a fall risk protocol was not initiated, seizure precautions were not implemented. The sepsis screen inaccurately indicates the patient did not have a history of acutely altered mental state or change in mental status, however, the sister reported that the patient had an episode of loss of consciousness. The physician wrote an order for oxygen to be administered, however the order was incomplete and did not indicate the amount and rate of oxygen administration and there was no documentation that oxygen was administered to the patient. The physician also wrote an order for an EKG and there was no documentation that the EKG was done. There was no documentation that the nursing staff performed a reassessment of the patient after the initial assessment, as required by the facility's policy. Review of the facility's policy titled "Assessments of Patients in the Emergency Department," which was last reviewed in 4/15 states, "Reassessments are performed on each patient at a minimum of every 2 hours or sooner." This patient was a triage level II, had a loss of consciousness and he was in the ED for more than 3 hours. There was no GCS (Glasgow Coma Scale) score (to assess the patient's level of consciousness following the reported fall with episode of loss of consciousness), throughout his stay in the ED. There was an order for a neurology consultation but there is no documentation that this was done. The ED physician also noted "In the ED, Patient with seizure activity." It could not be determined whether the patient had another episode of seizure activity while he was in the ED because the nurse's notes did not reflect this episode. There is no documentation that The ED physician performed a neurology reassessment throughout the patient's stay in the ED. Documentation states the patient was given discharge instructions at 10:29 PM that night, with a discharge diagnosis of [DIAGNOSES REDACTED] During interview on October 27, 2015, at 11:35 AM, The Director of the ED stated that a "discussion" with the on-call neurologist was done, that a neurology consultation may not have been necessary and that he concluded that the care was appropriate. (3) Review of MR #5 revealed this eighty year old patient presented on September 12, 2015 at 3:57 PM, after he had fallen that day. At 4:03 PM the patient was unconscious, in respiratory distress and he had a heart rate of 83 and a B/P of 152/83. The GCS score was 3, which is abnormal. There was no documentation of a respiratory rate or oxygen saturation. The patient was intubated at 4:10 PM and attached to a ventilator. A CT-Scan of the head and face showed the patient had extensive subarachnoid and intraventricular bleed and left orbital and left nasal fractures. The neurosurgeon was paged at 4:20 PM and she returned the call 5 minutes later. The record contained an entry at 7:47 PM that night which indicated the patient's condition was "dismal." The ED physician documented that "multiple re-evaluations " were done but the results of these re-evaluations were not documented. There was no documented evidence that the neurosurgeon saw the patient and performed a physical assessment, and her notes were "incomplete." (4) Review of MR #2 revealed this is sixty-two year old patient presented on October 25, 2015, 12:12 AM, with a complaint of left sided chest pain which had radiated to her shoulder and which had hurt when she breathed. The patient's pain score was 6 on a scale of zero (0), no pain to 10, worst pain. The patient had a previous medical history of [DIAGNOSES REDACTED]"sinus rhythm with premature ventricular complexes, possible anterior infarct 1/5/15, premature supra[DIAGNOSES REDACTED] now present." There was no documentation to indicate that this EKG was reported to the doctor or that the other protocols for chest pain were initiated. There was no documented evidence that the patient was placed in a bed or attached to a continuous cardiac monitor. The patient left from the waiting area at 12:46 AM that morning without been seen by a physician or medical practitioner. The policy titled "Chest Pain Guidelines," which was last revised 12/08 states, "the patient is placed in the first available appropriate patient care area. The triage RN will notify the charge RN of the patient and document this notification in the nurse's notes." The policy also states, "Follow advanced Triage Protocols, including: Labs, CXR, EKG to MD stat, O2 2-3 L via N/C, Saline Lock, pulse ox, cardiac monitor. Consider Aspirin, Beta Blockers and Pain Management." There was no documented evidence that any portion of this protocol was implemented. (5) Patient MR# 8, presented on March 13, 2015 at 8:45 PM, with a complaint of epigastric pain radiating to his chest, nausea and vomiting. The patient did not have a previous medical history but he had a history of drinking alcohol. The pain was sharp, acute and shooting and it was scored at 9 on a scale of zero (0) to 10. The patient was medicated with Zofran and Protonix and IV fluids were administered. At 3:00 AM, the physician documented that the patient's chest pain was returning and decided that the patient should be admitted . The nurse did not reassess the patient's pain score until 7:45 AM, almost 12 hours after his arrival and at this point the pain was still elevated at 8 on a scale of 10. There were no further re-assessments of the pain score. The patient remained in the ED for more than twenty (20) hours before signing out against medical advice at 3:49 PM, on March 14, 2015. All findings in the medical records were witnessed by the ED Lead Clinical Analyst, on October 26, 27 and 29, 2015.