Based on Medical Record review, document review and interview, the facility failed to perform timely radiological testing for patients meeting the facility's trauma criteria, in two (2) of four (4) Medical Records reviewed. Findings include: The Policy and Procedure titled, "Trauma Activation Procedure" last reviewed 05/03/18, stated: "...to assure that patients with concerning MOI [ Mechanism of Injuries] are seen in an expeditious manner and to prevent delay in detecting possible injuries...activation of a trauma alert criteria includes for an Adult, having a fall from any height if taking a blood thinner...all imaging studies will be given priority in the Emergency Department (ED). Based on the MOI, either Triage Nurse or ED provider will have trauma alert activated. The patient will be triaged immediately to an acute bed in the ED...X-Ray, CT and Laboratory will prioritize workups for these patients when the alert is called. All lab work and imaging studies for these patients will take priority in the ED." Review of Patient #1's Medical Record identified the following: Patient #1, with a history of taking Xarelto [a blood thinning medication], (MDS) dated [DATE] at 12:42PM via ambulance. Patient #1 had fallen, then subsequently hit her head. Patient #1 denied complaints of nausea, vomiting or numbness. An Emergency Severity Index (ESI) Level 2 was assigned. The ED Physician ordered a Trauma Alert Activation at 12:54PM. The Trauma Alert Order Set included a CT scan of the head. The ordered CT scan was not performed until 4:50PM, four (4) hours after the CT Order was placed. There was no documented evidence as to why the CT scan was delayed for this length of time. Review of Patient #2's Medical Record identified the following: This [AGE]-year-old arrived at the ED by ambulance on 01/12/19 at 2:54PM. Patient #2 had fallen at home and was on Plavix [a blood thinning medication]. An ESI Level 2 was assigned. The Physician ordered a Trauma Alert Activation at 2:55PM which included a CT scan of the head. The CT scan of the head was not performed until 5:58PM, three (3) hours after the Order was placed. Two (2) days later, on 01/14/19 at 12:40PM, Patient #2 returned to the ED by ambulance after once again falling at home. Patient #2 was still on Plavix. An ESI Level 2 was assigned. The Physician ordered a Trauma Alert Activation, including a CT scan of the head, at 1:00PM. The CT scan of the head was not performed until 6:59PM, six (6) hours after the Order was placed. There was no documented evidence as to why the CT scan was delayed for this length of time. Per interview of Staff F (Director of Radiology) on 03/05/19 at 11:20AM, the ED has a dedicated CT Scanner and all Radiological Tests in the ED are ordered "Stat". The Trauma Alerts are a higher priority than a "Regular Stat". However, because there are no clear and distinct thresholds or criteria for this category, they [Trauma Alerts] won't necessarily be performed as an immediate high priority. The Regular Stat CT scans are performed in the order we receive them, unless a Physician calls us to say do it immediately. It would be better if the wording were changed because as of now, 100% of all the Radiology Tests ordered in the ED are ordered Stat." Upon request of a facility Policy and Procedure listing the sublevel types of Stat Orders and their respective criteria, Staff F stated that the facility does not have such a Policy. On 03/05/19 at 12:00PM these findings were discussed with Staff A (Assistant Vice President of Quality) who acknowledged these findings.

. Based on medical record (MR) review, document review and interview, the facility failed to confirm the receiving facility had agreed to accept a transfer in one (1) of eight (8) MRs. Findings included: Review of Patient #5's MR identified the following information: This [AGE]-year-old (MDS) dated [DATE] at 5:56AM with a complaint of vaginal bleeding at twenty-two (22) weeks of pregnancy. Patient #5 was examined by a physician who documented the medical necessity to transfer the patient. The facility's Authorization for Transfer Form, dated 08/18/18, did not contain documented evidence that a physician at the receiving facility had been contacted and had accepted Patient #5 for admission. Per interview of Staff E (Medical Director) on 02/06/19 at 11:05AM, Staff E stated, "Our policy is for our physician to contact the receiving hospital and get a physician to accept the patient. This is done doctor to doctor. It should be documented in the medical record." The facility policy and procedure (P&P) titled, "Transfer of the Emergency Department Patient to Another Facility," dated 02/17/17 stated, "...the receiving hospital must give acceptance in advance and acceptance must be made physician to physician. The acceptance must be documented in the medical record along with the receiving hospital physician name..." The facility failed to confirm that the receiving hospital had agreed to accept the transfer.

. Based on observation, document review, and interview, the facility did not: (A) have a Policy for the Monitoring of Waiting Room Patients Awaiting a Medical Screening Exam (MSE), and (B) ensure in three (3) of five (5) Medical Records, that patients in the Treatment Area were not reassessed as per facility Policy and Procedure. This potentially places patients at increased risk for unassessed changes in their medical condition. Findings pertinent to (A) above include: Observation in the facility's Emergency Department (ED) during a tour between 10:30AM and 1:00PM on 01/09/17 identified the following: Patient #8 was observed waiting in the Waiting Area. The patient's spouse approached the Triage Desk at 12:23PM and stated that Patient #8 had been waiting for an hour and a half (1½) and was complaining of headache and now dizziness. Review of Patient #8's Medical Record identified the following information: This [AGE]-year-old arrived to the ED on 01/09/17 at 10:56AM, after a Motor Vehicle Crash (MVC). Patient #8 was triaged at 11:19AM with a chief complaint of head, neck and back pain, eight (8) out of ten (10) in severity. Initial vital signs were documented during triage on 01/09/17 at 11:23AM. No reassessment was documented for this patient while he was in the Waiting Area. During an interview with Staff G on 01/10/17 at 10:00AM, Staff G stated that "I personally check and eyeball the patients about every twenty (20) minutes but I don't recheck their vitals". Per interview with Staff L on 01/11/17 at 11:20AM, Staff L stated that [staff] checks on the Waiting Room Patients every five (5) to ten (10) minutes. This inconsistency in the reassessment of Waiting Room Patients was confirmed during interview with Staff Members B and C on 01/10/17 at 1:35PM. Staff B stated "The staff is trained to check on patients periodically but there is no specific Policy on reassessing patients in the Waiting Area". Staff C confirmed these findings. Findings pertinent to (B) above include: The facility's Policy and Procedure (P&P) titled "Measurement of Vital Signs [VS]" last revised 08/31/16, stated "If a patient presents with a stable primary assessment, including vital signs within normal limits, they are to be repeated every four (4) hours while the patient is waiting a disposition". This Policy refers to all patients who are assigned to a Treatment Area. Patient #17's Medical Record identified that on 01/10/17 the patient arrived to the ED at 8:44PM after a fall, had initial triage VS performed at 8:52PM, and repeat VS performed on 01/11/17 prior to discharge at 6:31AM. Repeat VS were not performed for approximately nine (9) and a half hours (9½) after the initial VS. Patient #16's Medical Record identified that on 12/28/16 the patient arrived to the ED at 1:09AM, after running out of home oxygen at the assisted living facility, and had initial triage VS performed at 1:45AM. Repeat VS were not performed until 8:38AM, approximately six and a half hours (6½) after the initial VS. Discharge VS were performed at 5:02PM, nine (9) hours after the repeat VS. Similar findings were found in the Medical Record of Patient #14 for the review period of 11/29/16 to 11/30/16. Per interview of Staff B and Staff M on 01/11/17 at 12:30PM, they stated that only patients with medical issues in the Treatment Areas should have VS repeated every four (4) hours as per their Policy. The current Policy does not distinguish between medical and non-medical patients.

. Based on Medical Record review, document review and staff interview, the Emergency Department Staff failed to ensure: 1) Implementation of the facility's Policy, and to appropriately document the means of transportation for patients released from the emergency room resulting in a potential for patients to have an unsafe mode of departure home in two (2) out of six (6) Medical Records reviewed, 2) that patient / family consent was obtained for the patient to remain in the Emergency Department (ED) eight (8) hours after admission, or that the "Transfer Option" Policy was updated to reflect the current process, resulted in the potential for patients not being given the opportunity to transfer to another facility. Findings: 1) Review of Patient #10's Medical Record (MR) revealed that the patient (MDS) dated [DATE] at 11:23PM by ambulance with altered mental status. The patient was documented to be yelling and incoherent with rambling speech. The Physician documented that "The patient was monitored closely overnight" and "Gradual improvement in exam and mental status over the evening". The Physician further documented "There are no significant changes from baseline labs". "He states that he (the patient) does not want to stay in the Emergency Department / Hospital", and that "The patient is able to ambulate and speak clearly at the time of discharge home". The Nurse's Clinical Note documented at 6:58AM on 09/25/15 that "The Plan of Care was discussed with patient", "Patient discharged with printed instructions, verbalized understanding and able to comply". There is no documentation in the Medical Record regarding the patient's "Mode of Departure" which was listed in the Emergency Department (ED) Log as "Unknown". Review of Patient #13's, Medical Record revealed that the patient (MDS) dated [DATE] at 12:16PM by ambulance after being in a motorcycle accident. The patient sustained road rash to multiple areas on her back and extremities and complained of right ankle pain. The patient's x-rays were negative and she was diagnosed with a strain and multiple abrasions / contusions. The Nurse's Clinical Note at 3:03PM documents "discharged with prescriptions, given to patient and reviewed". "Patient verbalized understanding", and "Able to walk with safe steady gait on crutches, walking boot applied". There is no documentation in the Medical Record regarding the patient's "Mode of Departure", which was left blank on the Emergency Department (ED) Log. On interview at 2:30PM on 11/17/15, Staff D stated that "The Nurse discharging the patient should be completing (documenting) the "Mode of Departure" in the ED Record and that "The staff should know that the patient has a safe way to get home". During an interview with Staff K on 11/17/15 at 4:30PM, the staff member stated that the Nurse has to complete the Mode of Departure when the patient is discharged . They are instructed to choose the Mode from a drop down table that lists six (6) choices (air transport, ambulance, Police escort, private car, taxi or unknown)" and "When choosing unknown, they should document why in a Clinical Note". The facility's Policy and Procedure (P&P) titled "Documentation for Emergency Department (ED) Discharge Patients", last revised on 08/31/15, directed Nursing Staff to document in the ED Chart the Mode of Transportation home, but lacked guidance that directed the Nursing Staff to document in a Clinical Note why the patient's the Mode of Transportation was listed as "Unknown". 2) During an ED tour on 11/16/15 at 1:30PM, Patient #4's wife approached the Nursing Station desk and asked Staff A for an update on her husband's inpatient bed assignment status. Patient #4's wife stated "My husband has been here for over twenty-four (24) hours and I do not know what is going on". Staff A stated she would find Patient #4's Nurse to update her. Patient #4's wife added "He had a bed assigned on a floor before but I do not know why it was taken away". When asked if anyone had spoken to them about their wait, or offered an alternative option, she stated "No, no we weren't". Review of Patient #4's Medical Record identified that the patient had initially (MDS) dated [DATE] at 9:32AM with right-sided weakness and altered mental status. Patient was admitted at 12:21PM. Patient had been housed in the ED for twenty-five (25) hours and was awaiting a bed assignment on the 4th Floor Telemetry Unit for TIA (Transient Ischemic Attack) rule out / CVA (Cerebral Vascular Accident). The findings were discussed with Staff Members A and D who both stated that they were not entirely clear on the Policy for admitted patients waiting in the ED. Interview with Staff C on 11/16/15 at 2:00PM revealed that ED patients who are admitted and waiting for a Unit Bed assignment are offered the opportunity to transfer to another facility. Staff C stated that patients are offered a transfer option eight (8) hours after admission, then every twenty-four (24) hours thereafter while they remain in the ED. Staff C stated that the West End Unit Secretary offers the patient the option to transfer and then documents the patients' names and responses in a Log. The West End Unit Secretary then notifies the RN who is responsible for documenting a Note in the patient's Medical Record. The Logs are kept in a binder at the West End Nursing Station. Document review of the ED admitted Patient(s) Eight Hours or Greater Data Log revealed the following: Patient #4 was admitted on [DATE] at 12:21PM. He was first offered the option for transfer on 11/16/15 at 8:00AM, nineteen (19) hours and thirty-nine (39) minutes after admission. No RN documentation stating the patient had declined or consented to remain in the ED was found in the Medical Record. Patient #11 was admitted on [DATE] at 7:29AM. He was first offered the option for transfer on 11/16/15 at 8:00AM, twenty-five (25) hours and thirty-one (31) minutes after admission. No RN documentation stating that the patient had declined or consented to remain in the ED was found in the Medical Record. Similar lack of documentation for eight (8) hour transfer option offers were found in the Medical Records for Patients #5, #14, #15 and #16 for a review period of 11/15/15 to 11/16/15. ED admitted Patient(s) Eight Hours or Greater Data Log pages for 11/10/15, 11/11/15 and 11/12/15 were not in the binder. Interview with Staff B on 11/16/15 at 2:30PM revealed that Log Sheets should have been completed for those days. Staff B explained "When I'm here, I complete the Log. If no one is waiting, then I draw a line through it for the day. I don't know what happens on days that I am not here." This was confirmed with Staff C. Patient Visits Lists for 11/10/15, 11/11/15 and 11/12/15 reflected the following: On 11/10/15, out of thirty-three (33) total patients who presented to the ED, and were subsequently admitted , fourteen (14) patients were housed over eight (8) hours, four (4) patients were housed over twenty-four (24) hours and one (1) patient was housed over forty-eight (48) hours. On 11/11/15, out of thirty-eight (38) total patients who presented to the ED and were subsequently admitted , thirteen (13) patients were housed over eight (8) hours and one (1) was housed over twenty-four (24) hours. On 11/12/15, out of twenty-nine (29) total patients who presented to the ED and were subsequently admitted , five (5) patients were housed over eight (8) hours and one (1) was housed over twenty-four (24) hours. These patients were not listed on the Log as having been offered the option to transfer (or consented to remain in the ED) until a Unit Bed was assigned. The facility's Policy and Procedure (P&P) titled "Transfer of the Emergency Department Patient to Another Facility", last approved on 09/06/12, stated the following: "Patients / family shall be offered the opportunity for transfer if ... admitted to the Inpatient Service but are awaiting a specific bed assignment ... ", or "Consent to remain at BMHMC [Brookhaven Memorial Hospital Medical Center] secured ... ". This process will be repeated every twenty-four (24) hours while the patient remains in the ED. The "ED admitted Patient(s) Eight Hours or Greater Data Log" stated the following: "The admitted patient(s) who are at the 8 [eight] hour mark will be offered the option to transfer to another hospital. Patients will then be offered an opportunity to transfer every 24 [twenty-four] hours after their first 8 [eight] hours of waiting for an admitted bed [as] follows: 1. The script above will be read to every admitted patient(s) who are at the 8 [eight] hour or greater mark by either the assigned Unit Secretary / Charge Nurse / Assistant Nurse Manager or Nurse Manager. 2. If the patient(s) accepts the option, the District Nurse is notified, who in turn will notify the patient's Physician, Case Management, and the Throughput Coordinator. Documentation must be provided in the Soarian System regarding the patient's request by the District Nurse. 3. If the patient(s) defers the option, the District Nurse will document the patient's decision in the Soarian System ... ". The facility's Policy and Procedure (P&P) titled "Transfer of the Emergency Department Patient to Another Facility", last approved on 09/06/12, stated the following: "... It will be the responsibility of the ED Assigned Unit Secretary ... to offer the opportunity for transfer to ED patients who have been admitted but await bed assignment ... . The RN Logistics Throughput Coordinator will document the patient's response to the opportunity for transfer on the Eight (8) Hour Rule for admitted Patients Pending Bed Assignment Form. Each 24 (twenty-four) hour period will require a new form. Signed forms will be kept in the Medical Record." During interview with Staff C on 11/17/15 at 10:10AM, when asked if this Policy reflected the current process, Staff C stated "No it does not. We no longer do it this way." She explained "This [Policy] is not correct. We use the Log. This form [the Eight (8) Hour Rule for admitted Patients Pending Bed Assignment Form] does exist and is given to the patient on admission, signed by the patient and added to the chart, but no one really reads this, so we started the Log instead. The new process is outlined in the Log Sheet. The process was changed because they needed someone who is here on a 24/7 (twenty-four hour / seven days a week) basis to do this." This finding was confirmed with Staff J.