Based on medical review, document review and staff interview, the facility failed to effect a safe transfer to a receiving facility in proximity to the transferring hospital to minimize the risk to the health of the patient and her unborn child. This failure placed the patient and her unborn child at risk for harm. Findings include: Review of medical record for Patient #1 identified a [AGE]-year-old female at eight months' gestation who was triaged in the Emergency Department (ED) on 12/13/16 at 1:06 AM with a chief complaint of vaginal bleeding. The patient reported, "Bleeding started prior to arrival in the ED, the color bright red with clots." The patient also complained of abdominal pain which she rated as seven (7) on a Pain Scale Index of one (1) to 10. Triage vital signs were as follows Temperature (T) 97.6, Pulse (P) 102, Respirations (R) 19, and Blood pressure (BP) 120/85. On 12/13/16 at 1:48 AM, Staff B (ED physician) documented, "A [AGE]-year-old female Gravida (Pregnant woman)1, pregnancy 0, abortion 0; 8 months pregnant female with past medical history of asthma presents to the ED complaining of heavy vaginal bleeding and lower abdominal cramps since 12:00 AM. The patient reports that she didn't feel well yesterday and had nausea and vomiting and thought it was food poisoning. The patient has had regular follows ups with her gynecologist in another hospital and has had regular ultra sounds. Otherwise, she reports no other acute complaints. The patient's last normal monthly period was 4/23/16." Review of system noted positive lower abdominal cramping and positive vaginal bleeding. Examination of the patient noted "positive gravida, abdomen soft non-tender, No guarding or rebound." At 2:32 AM, physician noted Doppler heart beat as 120 (normal: 120 - 160) and patient will be transferred to another facility. At 2:41 AM, ED nurse documented "fetus heart rate 104 measured by portable Doppler, ED physician was present while Doppler was in use. Patient is awaiting transportation to L&D (Labor and delivery)." At 2.51 AM, Staff B ordered the transport for patient #1 to Facility B that was approximately one hour away. The physician noted the reason for transfer is Specialty Care unavailable at Mount Sinai Brooklyn site. Level of care required during transportation is Paramedic Condition guarded. Reassessment of the patient's vital signs at 2.57 AM noted: T-97.8, P-112 (Normal 60 -100 beats per minute), R-18, BP-99/65, Oxygen saturation -100 percent. There was no evidence of a reassessment of the patient's vital signs and the heart rate of the fetus prior to the transfer of the patient to Facility B on 12/13/16 at 3:30 AM. Review of medical record for Patient #1 at Facility B, revealed the patient arrived at the facility on 12/13/16 at 4:20 AM, approximately one (1) hour after departure from the transferring facility. The initial sonogram after her arrival at the facility on 12/13/16 at 4:20 AM revealed an absence of fetal heart rate and a diagnosis of Placenta Abruption (Placenta separating from the wall of the uterus.). Review of facility's policy titled 'Inter - Hospital Transfer "last revised January 2016 notes the purpose is "To establish protocols for centralization of patient transfers throughout the Health Systems. The Patient Transfer Coordinator will be responsible for transferring patients from a hospital or urgent care center to one of the hospitals within the health system and will be the central liaison to work with the respective Finance Departments, Bed Management and the Referring and Accepting physicians, The Patient Transfer Center Coordinator will be responsible for communicating with all parties involved maintaining a seamless transition between institutions for all patients transfer(s)." There was no documentation in the medical record that the facility attempted to secure transfer to a facility near the hospital to minimize the risks to the patient's health and her unborn child. At interview with Staff A, Director of Emergency Department on 06/22/17 at approximately 11:15 AM, she stated that the facility did not have an obstetrics and gynecological (OB/GYN) service and that transfer was required for Patient #1. Staff A stated that it was the ED physician's decision to transfer the patient to a facility within the Health System. Staff A stated she is unable to provide the justification for staff B decision regarding the patient's transfer.

Based on medical record review, document review and interview, it was determined that the Emergency Department (ED) failed to follow the facility's policy to: (a) provide a Suicide Risk Assessment to a patient seeking emergency psychiatric service, and (b) provide a safe discharge from the ED. This was found in one (1) of 10 medical records reviewed (Patient # 1). This deficiency may have placed patients at risk for potential harm. Findings: See Tag A1104.

Based on medical record review, document review and staff interview, it was determined that the Emergency Department failed to adhere to the facility's policy to provide: (a) a Suicide Risk Assessment for a patient presenting with suicidal ideation, and (b) provide discharge services to meet the safety needs of the patient. This was found in one (1) of 10 medical records reviewed (Patient # 1). Findings include: Review of the medical record for Patient #1, found that on 3/18/16 at 2111 (9:21 PM), the patient presented to the emergency department's Comprehensive Psychiatric Emergency Program ( CPEP) unit by EMS ambulance, with the chief complaint of "suicidal. " The Pre-Hospital Care Report (PCR) was noted by EMS staff, that the patient was found crying on the curb stating that she wants to die and that she wants help. She also reported that she has been non-compliant with her psychoactive medications and seizure medications (Tegretol and Neurontin) for 6 days. There was also an admission of doing "crack - cocaine and smoking "MJ" today. After an initial triage at 2111 (9:21 PM), the patient was found suicidal and assigned the ESI (Emergency Severity Index) #3 (Urgent - treatment and reassessment should occur within 2 hours). The patient and EMS personnel were directed to CPEP (Comprehensive Psychiatric Emergency Program) at 2142 (9:42 PM). The CPEP nursing documentation in the medical record indicated that for approximately two (2) hours of the time spent in CPEP, the patient was noted as "patient sleeping in geri chair in hall " . The medical assessment by the Psychiatric Resident on 3/19/16 at 0022 (12:22 AM) noted the patient's chief complaint was "I want to kill myself." She reported that she was having "suicidal thoughts " . The patient reported a history of bipolar disorder, seizures, and asthma. She admitted to using crack-cocaine prior to admission. A brief review of systems (ROS) was noted in the record by the Resident as being positive for suicidal ideation. The resident also noted that the patient would be held and re-evaluated. At 3/19/16 0049 (12:49 AM), the attending physician noted that he reviewed and signed off on the Resident's note. There is no other entry by the attending physician until the "chart note " on 3/19/16 at 0326 (12:36 AM) that "Patient with crack-cocaine dependence, demanding in CPEP to be admitted as she does not have a place to live. Patient became belligerent, demanding to leave, reported very vague ideas to hurt herself that are conditional to be admitted to the hospital - patient is malingering." The attending physician discharged the patient at approximately 3:30 AM on 3/19/16 without any documented focused assessment of the patient's risk of suicide that triggered the patient's visit to the CPEP. There is no documented evidence that the patient received a Suicide Risk Assessment as required by the facility's policy. Review of the Policy and Procedure titled "Suicide Risk Assessment " , dated 6/2/14, states that the Suicide Risk Assessment must be completed by a physician, must describe specific levels of risk, including current symptoms and lack of supports. There was no documented evidence that such a risk assessment was completed by any of the physicians involved in the care of this patient. There was no assessment of the risks of the patient's stated non-compliance with her medications for 6 days. There was no order for a toxicology screen or EKG related to the patient ' s presentation to the ED with a reported history of recent substance abuse of undetermined quantity or frequency, and no assessment of drug amounts that she recently reported as having ingested to rule out potential for overdose. The patient ' s primary diagnosis, however, was noted as "Cocaine Abuse- Non complicated." The discharge instructions, which was noted, "patient refused to sign " , focused on the need for drug rehabilitation and had no reference to suicidality that triggered the patient's visit to the ED. There was no discharge plan to address the immediate issue of homelessness or noncompliance with psychoactive medications for six (6) days. The facility's Comprehensive Psychiatric Emergency Program (CPEP) procedure titled "Discharge Services," revised 11/2014, states "Discharge planning services will be provided to all patients and their families/significant others who are receiving CPEP services. The patient's current situation and aftercare needs will be assessed to include referrals to appropriate aftercare programs and ass concrete services." This procedure was not followed with the patient. The psychiatric assessment process and treatment plan did not record the specific reasons why the patient was not a candidate for inpatient psychiatric admission and did not fully document the details of the suicidal "ideas " . During interview with the attending psychiatrist on 4/25/16 at 1:00 PM, he stated the following: he had no intention to admit the patient to an inpatient unit from the time the patient arrived in the CPEP. The patient came in posturing with a "crack dance" and was malingering, using suicidal ideation to be admitted to an inpatient psychiatric unit because she was homeless. He offered the patient to stay in the CPEP until 7:00 AM when the patient could be assessed for possible admission to the hospital detox unit. There is no documented record of this treatment plan. The medical record noted that the patient became belligerent prior to leaving the CPEP at approximately 0336 (3:36 AM). Review of hospital Quality Assurance Report on 4/25/16 indicated that the patient was struck and killed by an automobile, in front on the Hospital's main entrance, minutes after leaving the CPEP on 3/19/16 at approximately 3:40 AM.