Based on medical record review, document review and interview, in two (2) of sixteen (16) medical records reviewed, the hospital did not effectively implement its Observation Policy so that patients who presented to the Emergency Department (ED) with suicidal ideation were properly monitored,and that physician's orders were renewed (Patient's #2, #3). Findings include: During touring the Pediatric Emergency Services on 10/31/18 at approximately 12:45 PM, Staff G, Nurse Aide was observed sitting in a chair outside bays PED 6 & PED 7. Her seat was located between both bays. During interview with Staff G at the time of observation, this Staff stated both patients were in the ED for suicide attempts and she was providing 1:1 observation for safety. Review of MR for Patient #2: [AGE]-year-old with history of suicide attempt was brought in by ambulance on 10/29/18 at 8:09 PM, accompanied by his mother, after he attempted to commit suicide by strangulation using an electric wire. On 10/29/18 at 8:10 PM, the patient had a medical evaluation and the provider ordered the patient placed on 1:1 observation (Arm length). On 10/29/18 at 11:39 PM, the patient had a psychiatrist evaluation and it was determined the patient required inpatient psychiatry admission for stabilization. On 10/31/18 at 11:46 AM, the physician documented that 1:1 observation be continued as the patient posed danger to self. . Review of MR for Patient #3: A [AGE]-year-old with history of depression, presented in the facility's ED on 10/30/18 at 4:45 PM expressing suicide ideation. The patient had a psychiatrist evaluation on 10/30/18 at 5:52 PM. The psychiatrist determined that the patient posed a clear danger to herself and needed impatient stabilization. The patient was to remain on 1:1 observation for safety until transfer to a hospital willing to accept the patient. Review of the "Progress Record & Behavioral Checklist" form, dated 10/31/18, noted for Patients #2 & Patient #3, from 12:30 PM -1:00 PM both patients were monitored by Staff G. On 10/31/18 from 1:30 PM -2:00PM, both patients were monitored by Staff H. Review of facility policy titled: "Close and Constant (1:1) Observation for General Hospital Patients," revised 12/7/17 states; "the staff member assigned to Constant/One to One (1:1) observation will remain within arm's length of the patient and maintain visual contact at all times until relieved by another staff member for meal/ breaks." The policy was not implemented as these patients were not in arm's length of the staff observing them. During interview with Staff E, ED RN Manager, on 11/2/18 at approximately 1:00 PM, Staff E acknowledged that Staff G was not correctly monitoring the patients. She stated that Staff G was assigned to One to One observation for Patient #2 and Staff H was assigned to One to One Observation for Patient #3 but Staff H went for her break without notifying the nurse in charge. Staff E stated that staff providing 1:1 observation did not have to be within arm's length of the patient. Review of MR for Patient #2 noted on 10/29/18 at 8:10 PM, the patient had a medical evaluation and the provider ordered the patient placed on 1:1 observation (Arm length). The order was dated on 10/29/18 8:20 PM: Frequency: continuous x 24 hours. There was no documentation that this order was renewed after 24 hours. Review of facility policy titled: "Close and Constant (1:1) Observation for General Hospital Patients'" revised 12/7/17 states; "Constant / One to One (1:1) Observation requires a physician's order and the order must be renewed every 24 hours. This policy was not implemented as there was no documented evidence that the order for 1:1 Observation was renewed.

Based on medical record review, document review and interview, the facility failed to ensure that patients in the Emergency Department (ED) are assessed, evaluated and monitored by the clinical staff in a timely manner and in accordance with the facility's policy and procedure. This was evident in one (1) of thirteen records reviewed. This delay in assessment and monitoring resulted in patient harm. Findings include: See: Tag A-1104.

Based on medical record review, document review and staff interview, the facility did not ensure that the patient in the Emergency Department (ED) was assessed, monitored and evaluated by the clinical staff in a timely manner and in accordance with the facility's policy and procedure. This was evident in one (1) of thirteen records. (Patient #1) This delay in assessment and monitoring resulted in patient harm. Findings include: Review of the medical record of Patient #1 identified the following: A [AGE] year old female with a history of depression and anxiety, was brought to the ED by EMS on 1/31/16 at 9:41 PM. The chief complaint reported by the family member to EMS was that the patient was "acting out in the last hour." The family member explained that the patient had no history of drug abuse, and that this episode of irrational behavior was a new onset. The patient was triaged at Level 3 (Urgent) on 1/31/16 at 2202 (10:02 PM) for the chief complaint of "Erratic behavior." The triage nurse noted that she was unable to obtain vital signs because of the patient's behavior. The patient was described as being uncooperative. The facility's policy titled "Triage of Emergency Department Patients," requires the RN to assess the patient and determine the Emergency Severity Index (ESI) level. The ESI levels from 1 - 5 identifies the need for treatment, based on patient symptoms, within a specific time frame. For example, Level 1 requires immediate treatment, Level 2 requires treatment within 30 minutes, and Level 3 requires treatment within 1 hour. The triage classification chosen by the nurse was not appropriate for this patient. Current practice based on the "Emergency Severity Index version 4 Implementation Handbook," recommends a Level 2 for a patient presenting with new onset altered mental status, confusion, severe pain or distress. The lack of vital signs at the time of triage is contrary to the facility's policy. The failure to establish a baseline at the time of presentation may negatively impact a patient's treatment because it may hinder the practitioner's ability to identify some of the patient's needs. There is no documentation to determine if the nurse made another attempt to obtain this baseline assessment in a timely manner. On 1/31/16 At 2319 (11:19 PM), approximately 1 hr and 20 minutes after arrival in the ED, the patient's primary nurse, Staff B, noted the Nursing ED Assessment: vital signs of Temperature 101.3 F (Fahrenheit, normal 97.8 degrees F to 99 degrees F for a healthy adult) , Pulse 105 beats per minute(normal 60 to 100 beats a minute), Blood Pressure 134/88, Respirations 20, Oxygen Saturation 98%. The nurse also noted the patient was alert and responsive to verbal stimuli by opening her eyes. The patient was connected to oxygen and continuous saturation monitoring. The patient's temperature and heart rate were abnormal and there was no documented evidence of monitoring or a follow-up investigation of these findings until after the patient coded at approximately 2:50 AM on 2/1/16. There was no documentation by Staff B that the patient was in a 4 point restraint at this time. Upon arrival to the ED and after removal of the EMS restraints, the patient was placed in 4 point restraints by the primary nurse, Staff B. This is documented on 1/31/16 at 2202 (10:02 PM). This 4 point restraints was initiated prior to Staff B's nursing assessment at 11:19 PM. The patient was transported to a side room; she was attached to a pulse oximeter monitor. Post restraint application monitoring was not found in the patient's medical record. As per the facility's Policy for Restraints and Seclusion, a patient in 4 point restraints requires monitoring every 30 minutes. The policy also requires a Licensed Independent Practitioner (L.I.P) to perform a face to face evaluation within 30 minutes to determine the need for continuation of the restraints. The L.I.P must document his findings in a progress note. There was no practitioner progress note documenting an evaluation, the full rationale for the use of the restraint and the patient's response to the restraint application. These elements are required by the facility's restraint policy and is the current standard of practice. On 1/31/16 at 2330 (11:30 PM) Patient #1 was ordered for 2mg Lorazepam intramuscularly (IM) and 5 mg of Haloperidol IM by the provider, Staff C; the medications were administered by Staff B at 11:30 PM. Staff B noted Staff C was at the bedside when the patient was medicated with Lorazepam and Haloperidol as ordered. A partial Initial History and Physical dated 1/31/16 at 2333 (11:33 PM) is noted by the provider, Staff C. The provider obtained much of his information from the family member present. He noted "Pt is sleeping and unable to assess neuro." With an incomplete assessment, the provider determined a primary diagnosis, namely; "Unspecified psychosis not due to a substance or known physiological condition." The provider's documentation on the patient was produced after he had ordered the psychotropic medications, which were administered by the nurse. There was no documentation related to the order and or the rationale for ordering these medications. At interview with Staff E on 2/24/16 at 2:30 PM, surveyors were informed that the usual practice at this facility is for physicians to assess their patients prior to ordering psychotropic medications. This practice was not reflected in the facility's "Medication Administration" Policy and this was not done by the provider in this case. A notation by Staff B, the primary nurse at 1:05 am on 2/1/16, indicated the patient was resting in the stretcher NAD (no acute distress) with oxygen via nasal cannula in use at 2 liters/minute. The nurse drew blood and collected urine at that time. There is no documentation about the patient's restraints at that point. There is no indication that they were either released or removed in view of the fact that the patient was noted to be "resting, in no acute distress." Patient #1 remained in the room until approximately 2:50 AM on 2/1/16 when she was found without a pulse by Staff B, the primary nurse. The patient was successfully resuscitated and intubated. She was moved to another area and was seen by cardiology services. She was started in intravenous antibiotics. She was admitted to the Medical Intensive Care Unit (MICU) and experienced four more episodes of cardiac arrest before she could be transported to the unit. She was pronounced dead after the last attempt at resuscitation at 8:22 AM on 2/1/16. At interview on 2/25/16 at 11:15 AM with the Attending Physician, surveyors were informed that she was called about 2:55 AM while she was finishing placement of a central line on another patient. It was the first time she had seen Patient #1 and she admitted she did not know how the patient presented because she was with another patient at the time.

Based on tour conducted of the Emergency Department, it was determined that signs specifying the rights of individuals with emergency medical conditions and women in labor, and whether the hospital participates in the Medicaid program were not posted conspicuously as required. Findings include: A tour of the Emergency Department conducted on 9/23/15, approximately 10:11 AM, noted hospital signage was not conspicuously displayed in the treatment and waiting areas of the Emergency Department. This was acknowledged by Staff #1 (Assistant Director of Nursing-ED), who was present during the tour.

Based on review document and interview, it was determined that the disposition of each individual seeking assistance in the ED was not consistently documented. Findings include: Review of the Emergency Department (ED) Central Log on 9/23/15, for the period April 1, 2015 - September 2015, noted chief complaints and dispositions for the months of June, July, August and September were not completed. It was determined that the facility failed to consistently meet all the requirements for maintenance of the ED central log. This finding was acknowledged by Staff # 1 (Assistant Director of Nursing-ED).

Based on review of document and staff interview, in one (1) of eight (8) medical records reviewed, it was determined that the facility did not effectively meet the requirements for providing an appropriate transfer of patients presenting to the Emergency Department (ED). Specifically, there was no physician documentation of (a) the reason for transfer and notification of the risks and benefits of the transfer, (b) confirmation that the receiving facility accepted the patient for admission. Findings include: Review of patient MR#A, on 9/25/2015, revealed: This [AGE] year old patient, on 9/7/15 0402 (4:02 AM) arrived to the ED via EMS with a Chief Complaint of EDP (Emotionally Disturbed Person). The Medical History significant for Herniated Disc, previous psychiatric admissions and on Zyprexa 5mg daily. The patient was triaged and assigned Triage Category ESI (Emergency Severity Index) 3-Urgent. Vital Signs noted to be: Temperature: 99, Blood Pressure: 130/81, Respirations: 18, Pulse: 88. The patient was seen and examined by the physician who determined that the patient was "poorly groomed, irritable, with severely disorganized thought process and poor insight into her behavior. She is paranoid about the boyfriend and his friends." Physician's documentation at 1147 (11:47 AM) noted that the patient "indicated that she is on a first pass (home visit) since she was admitted to Rockland State facility many months ago. She was transferred to a transition program there in August as per Rockland staff member. Was doing well on Zyprexa 5mg daily. Claimed to be compliant with it on pass. Presently denies any suicidal or violent ideation but is disorganized with poor judgment and needs a transfer back to her hospital for further stabilization. " It was noted that the "Inter-Hospital Transfer Record" for patient MR#A, dated 9/7/15, failed to adequately document the reason for transfer, noting "patient is a patient in Rockland Psych." There was no documentation to indicate that the patient/patient's representative was informed of the risks and benefits of the transfer, or why not. In addition, there was no physician's documentation to indicate that a physician at the receiving facility had been contacted and accepted the patient for admission and there was no documentation to indicate that a copy of the patient's ED chart was sent with the patient. Physician's documentation on 9/7/15 at 12:15 PM, indicated that the patient was paranoid, grandiose, irritable with severe thought disorder, no thought into her behavior, poor judgement, needs inpatient care and transfer back to the facility. However, the patient was transferred back to a transitional residence (outpatient) and not to a "hospital for further stabilization." This was brought to the attention of Staff #3 (MD, Chairman of Psychiatry) and Staff #4 (Social Worker) Mental Health. Upon interview on 9/25/15 at 1:50 PM, Staff #4 stated that she contacted the facility and spoke with someone in the admitting office and did not know that it was a transitional residence. The facility failed to provide an appropriate transfer to another medical facility.