Touro Infirmary

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 44495 Based on record review and interviews, the hospital failed to ensure hospital policies were followed by medical staff and training residents. The deficent practices included failure of the attending physician to examine the patient, failure of the attending physician to ensure the patient understood the consent after the initial consent was obtained by the resident for a medication only credentialed obstetrical staff could order, and inaccurate documentation in the medical record by the resident which was not reviewed and corrected by the attending physician (See Findings in Tag A0049).”

“MEDICAL STAFF - ACCOUNTABILITY CFR(s): 482.12(a)(5) [The governing body must] ensure that the medical staff is accountable to the governing body for the quality of care provided to patients. This Standard is not met as evidenced by: 44495 Based on record review and interview the governing body failed to ensure the quality of care provided by the medical staff. The deficient practice is evidenced by failure to ensure the attending physician performed requisite duties. Findings: Review of the Medical Staff Rules and Regulations, revised 12/12/2024, revealed in part, “The member of the Hospital Medical Staff acting as the credentialed supervising physician with Practitioners in Training shall: a. Be listed as the Attending Physician and be introduced to the patient, as the Attending Physician, who will be responsible for the patient’s care. b. Review the available information concerning the patient’s status, make appropriate examination of the patient, recommend desired changes in the medical record, and document approval of the plan of management of the patient.” Review of Touro Administrative Policy #274, “Methotrexate Single Dose for OB Patients with Ectopic Pregnancy,” approved 06/27/2023, revealed in part, “Only credentialed physicians of the Obstetric (OB) Medical Staff may order methotrexate. For OB patients with ectopic pregnancy. Residents may not order methotrexate. b.Verbal and telephone orders are unacceptable for methotrexate injections. The standard methotrexate order set will be used for all patients requiring the administration of intramuscular (IM) methotrexate.” Review of the medical record for Patient #1 revealed the patient presented to the emergency department on 05/15/2025 with complaints of vaginal bleeding and cramping in early pregnancy. A transvaginal ultrasound was performed and was documented as “findings concerning for ectopic pregnancy.” Review of the physical examination documented by Resident S6MD revealed, “RN chaperone present for the entirety of the exam.” In interview on 07/14/2025 between 1:11 PM and 1:22 PM, S6MD verified there was no one present for her examination of the patient as documented in her note. In interview on 07/14/2025 between 1:24 PM and 1:34 PM, S7MD verified that he was responsible for the accuracy of the documentation by the resident. S7MD also verified did not go down to the emergency department to perform an examination on the patient and he did not participate in the consent of the patient for the administration of methotrexate.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 48050 Based on record review, interview, and observation, the hospital failed to ensure each patient’s right to receive care in a safe setting. The deficient practice is evidenced by an unlocked procedure cart that contained sharps posing a potential risk for injury. Findings: On 07/09/2025 between 9:26 AM to 9:57 AM, a tour of the emergency department with S1EDD was conducted. The tour revealed an unlocked procedure cart in the hallway not far from the psychiatric holding room that contained scalpels, sutures, and needles which ED patients could access. In an interview on 07/09/2023 at 9:41 AM, S1EDD verified there was an unlocked procedure cart that contained scalpels, sutures, and needles in the hallway which ED patients could access.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48050 Based on record review and interview, the hospital failed to ensure a registered nurse supervised and evaluated the nursing care of each patient. This deficient practice was evidenced by: 1) failure of nursing staff to document vital signs as per hospital policy for 11 (#1-#10, #12) of 13 (#1- #13) patient medical records reviewed for vital signs from a total sample of 20 reviewed records; and 2) failure of nursing staff to document reassessments per hospital policy for 4 (#1, #5, #12, #15) of 20 (#1-#20) patient medical records reviewed. Findings: Review of hospital policy number ED.316, titled “Assessment of Patients in the ED” last revision 01/2025, revealed in part: “PROCEDURES: 5. Patients in treatment areas are re-assessed as appropriate related to age and severity of condition: c. Level 3- Urgent performed upon discharge and documented every 2 to 4 hours and more frequently if condition warrants 6. The reassessment includes vital signs in which pain scale is included, response to treatment, and changes from the previous assessment. Reassessment should be done anytime there is the following: -A change in patient condition - A significant change in patient vital signs -Treatment intervention -A specific physician’s order” 1)Failure of nursing staff to document vital signs as per hospital policy for 11 (#1- #10, #12) of 13 (#1-#13) patient medical records reviewed from a total sample of 20 reviewed records. Patient #1 Review of Patient #1’s medical record revealed Patient #1 presented to the ED on 05/15/2025 at 1:22 PM with complaint of Vaginal Bleeding and Abdominal Pain and triaged an acuity level 3. Further review of Patient #1’s medical revealed Patient #1 was discharged home at 8:42 PM. Review of Patient #1’s vital signs revealed the following: 05/15/2025 at 1:35 PM: Temperature 98.3, Pulse 106, Respirations 20, Blood Pressure (BP) 120/56, pulse oximeter 99 % on Room Air, and pain 8/10 05/15/2025 at 4:45 PM: Temperature 98, Pulse 91, Respirations 18, BP 119/58, pulse oximeter 100% room air, and no pain assessment done 05/15/2025 at 5:50 PM: Temperature 98.2, Pulse 89, Respirations 18, BP 122/62, Pulse oximeter 100% on room air, and no pain assessment done 05/15/2025 at 7:22 PM: Temperature 99.1, Pulse 91, Respirations 18, BP 124/56, Pulse oximeter 100% on room air and no pain assessment done 05/15/2025 at 8:40 PM: Temperature 98, Pulse 89, Respiration 18, BP 122/58, Pulse oximeter 100% on room air and no pain assessment done In an interview on 07/09/2025 at 3:00 PM, S1EDD confirmed the above mentioned findings. S1EDD also verified that Patient #1 was an acuity level 3 so per policy blood pressure, pulse, respiratory rate, O2 saturation, and pain should be documented every 2-4 hours while in the ED. Patient #2 Review of Patient #2’s medical record revealed Patient #2 presented to the ED on 07/04/2024 at 12:57 PM with complaint of Ectopic Pregnancy and triaged an acuity level 3. Review of Patient #2’s vital signs revealed the following: 07/04/2025 at 1:04 PM: Temperature 98.1, Pulse 110, Respirations 16, BP (Blood pressure) 154/89, Pulse oximeter 99% on room air, and Pain 4/10 documented 07/04/2025 at 1:05 PM: Pulse 112, Respirations 22, BP 158/84, pulse oximeter 98% on room air documented and Temperature or Pain was not assessed. Further review of Patient #2’s medical record revealed on 07/04/2025 at 2:00 PM Patient #2 was transferred to the operating room for surgery with no further vital signs documented. In an interview on 07/10/2025 at 10:20 AM, S3SDQPS confirmed the above mentioned findings. S3SDQPS also verified that Patient #2 was an acuity level 3 so per policy blood pressure, pulse, respiratory rate, O2 saturation, and pain should be documented every 2-4 hours while in the ED. Patient #3 Review of Patient #3’s medical record revealed Patient #3 presented to the ED on 07/03/2025 at 10:03 AM with complaint of vaginal bleeding and abdominal pain (pregnancy 11 weeks) with triage acuity level 3. Further review of Patient #3’s medical record revealed on 07/03/2025 at 1:12 PM Patient #3 was discharged home. Review of Patient #3’s vital signs revealed the following: 07/03/2025 at 10:09 AM: Temperature 97.5, Pulse 79, Respirations 14, BP 129/73, Pulse oximeter 100% on room air, and no pain assessed 07/03/2025 at 10:17 AM: Pain 7/10 07/03/2025 at 12:05 PM: Temperature 98.1, Pulse 69, Respirations 11, Pulse oximeter 100% on room air, and pain assessment not documented 07/03/2025 at 1:00 PM: Pulse 90, Respirations 12, Pulse oximeter 100% on room air, and Temperature or Pain not documented In an interview on 07/10/2025 at 10:40 AM, S3SDQPS confirmed the above mentioned findings. S3SDQPS also verified that Patient #3 was an acuity level 3 so per policy blood pressure, pulse, respiratory rate, O2 saturation, and pain should be documented every 2-4 hours while in the ED and at discharge. Patient #4 Review of Patient #4’s medical record revealed Patient #4 presented to the ED on 06/05/2025 at 3:31 PM with abdominal pain and vaginal bleeding with triage acuity level 3. Further review of Patient #4’s medical record revealed on 06/05/2025 at 6:40 PM was discharged home. Review of Patient #4’s vital signs revealed the following: On 06/05/2025 at 3:35 PM: Temperature 98.2, Pulse 90, Respiration 16, BP 124/58, Pulse oximeter 100% on room air, and patient denies pain In an interview on 07/10/2025 at 11:03 AM, S3SDQPS confirmed the above mentioned findings. S3SDQPS also verified that Patient #4 was an acuity level 3 so per policy blood pressure, pulse, respiratory rate, O2 saturation, and pain should be documented every 2-4 hours while in the ED and at discharge. Patient #5 Review of Patient #5’s medical record revealed Patient #5 presented to the ED on 05/24/2025 at 3:33 PM with vaginal bleeding and abdominal pain with triage acuity level 3. Further review of Patient #5’s medical record revealed on 05/24/2025 at 5:37 PM was discharged home. Review of Patient #5’s vital signs revealed the following: 05/24/2025 at 3:43 PM: Temperature 98.3, Pulse 84, Respirations 16, BP 127/76, Pulse Oximeter 100% on room air, and Pain 7/10 05/24/2025 at 5:00 PM: Pulse 82, Respirations 17, BP 130/78, Pulse oximeter 97% on room air- Temperature and pain not reassessed In an interview on 07/10/2025 at 11:30 AM, S3SDQPS confirmed the above mentioned findings. S3SDQPS also verified that Patient #5 was an acuity level 3 so per policy blood pressure, pulse, respiratory rate, O2 saturation, and pain should be documented every 2-4 hours while in the ED and at discharge. Patient #6 Review of Patient #6’s medical record revealed Patient #6 presented to the ED on 05/23/2025 at 2:58 AM with vaginal bleeding and triage acuity level 3. Further review of Patient #6’s medical record revealed on 05/23/2025 at 5:22 AM left the ER prior to discharge instructions. Review of Patient #6’s vital signs revealed the following: 05/23/2025 at 3:12 AM Temperature 98.1, Pulse 88, Respirations 21, BP 169/93, Pulse oximeter 100% room air, and pain 8/10. 05/23/2025 at 5:00 AM Pulse 59, BP 159/87, and Pulse oximeter 100% room air- Temperature, Respirations, and Pain not reassessed In an interview on 07/10/2025 at 11:50 AM, S3SDQPS confirmed the above mentioned findings. S3SDQPS also verified that Patient #6 was an acuity level 3 so per policy blood pressure, pulse, respiratory rate, O2 saturation, and pain should be documented every 2-4 hours while in the ED and at discharge. Patient #7 Review of Patient #7’s medical record revealed Patient #7 presented to the ED on 05/21/2025 at 7:23 PM for vaginal bleeding and abdominal pain and triaged an acuity level 3. Further review of Patient #7’s medical record revealed Patient #7 was discharge home on 05/21/2025 at 8:00 PM. Review of Patient #7’s vital signs revealed the following: On 05/21/2025 at 7:32 PM: Temperature 98.2, Pulse 95, Respirations 16, Pulse oximeter 100% on room- pain was not assessed In an interview on 07/10/2025 at 1:02 PM, S3SDQPS confirmed the above mentioned findings. S3SDQPS also verified that Patient #7 was an acuity level 3 so per policy blood pressure, pulse, respiratory rate, O2 saturation, and pain should be documented. Patient #8 Review of Patient #8’s medical record revealed Patient #8 presented to the ED on 05/21/2025 at 5:05 PM with complaint of vaginal bleeding-pregnant and triaged an acuity level 3. Further review of Patient #8’s medical record revealed Patient #8 was discharged home at 7:58 PM on 05/21/2025. Review of Patient #8’s vital signs revealed the following: 05/21/2025 at 5:26 PM Temperature 97.9, Pulse 68, Respirations 18, BP 128/71, Pulse oximeter 100% room air, and pain 0/10 05/21/2025 at 6:53 PM Temperature 98, Pulse 62, Respirations 18, BP 122/65, and Pulse oximeter 100% room air- pain was not reassessed 05/21/2025 at 7:58 PM Pulse 62, Respirations 18, BP 120/74, and pulse oximeter 100% room air- temperature or pain assessment done In an interview on 07/10/2025 at 1:16 AM, S3SDQPS confirmed the above mentioned findings. S3SDQPS also verified that Patient #8 was an acuity level 3 so per policy blood pressure, pulse, respiratory rate, O2 saturation, and pain should be documented every 2-4 hours while in the ED and at discharge. Patient #9 Review of Patient #9’s medical record revealed Patient #9 presented to the ED on 05/16/2025 at 12:47 PM for vaginal bleeding and abdominal cramping- pregnant and triaged an acuity of level 3. Further review of Patient #9’s medical record revealed Patient #9 was discharged home on 05/16/2025 at 4:53 PM. Review of Patient #9’s vital signs revealed the following: 05/16/2025 at 12:57 PM Temperature 98.5, Pulse 106, Respiration 18, BP 140/73, Pulse oximeter 99% room air, and no pain assessed 05/16/2025 at 3:39 PM Pulse 75, Respirations 11, BP 110/61, Pulse oximeter 100% room air- no temperature or pain assessed In an interview on 07/10/2025 at 1:33 P M, S3SDQPS confirmed the above mentioned findings. S3SDQPS also verified that Patient #9 was an acuity level 3 so per policy blood pressure, pulse, respiratory rate, O2 saturation, and pain should be documented every 2-4 hours while in the ED and at discharge. Patient #10 Review of Patient #10’s medical record revealed Patient #10 presented to the ED on 05/16/2025 at 7:36 PM with complaint of vaginal bleeding and suicidal ideations with triage acuity level 3. Further review of Patient #10’s medical record revealed Patient #10 was transferred to another facility on 05/17/2025 at 7:53 AM. Review of Patient #10’s vital signs revealed the following: On 05/16/2025 at 7:36 PM Temperature 98.5, Pulse 80, Respirations 18, BP 95/72, Pulse oximeter 96% on room air, and pain not assessed On 05/16/2025 at 8:58 PM Pulse 76, Respirations 21, BP 126/80, Pulse oximeter 97% on room air- Temperature and pain not assessed On 05/16/2025 at 9:00 PM Pulse 69, Respirations 16, BP 131/83, Pulse oximeter 97% on room air- Temperature and pain not assessed On 05/16/2025 at 9:18 PM Temperature 98.3, Pulse 68, Respirations 15, Pulse oximeter 97% on room air and pain not assessed On 05/17/2025 at 6:32 AM Temperature 97.8, Pulse 78, Respirations 20, BP 132/84, Pulse ox 98% room air and pain not assessed On 05/17/2025 at 7:44 AM Temperature 98.1, Pulse 81, Respirations 20, BP 141/97, Pulse oximeter 98% on room air and no pain assessed done In an interview on 07/10/2025 at 2:20 PM, S3SDQPS confirmed the above mentioned findings. S3SDQPS also verified that Patient #10 was an acuity level 3 so per policy blood pressure, pulse, respiratory rate, O2 saturation, and pain should be documented every 2-4 hours while in the ED and at discharge. Patient #12 Review of Patient #12’s medical record revealed Patient #12 presented to the ED on 07/08/2025 at 10:29 PM Vaginal Bleeding and Headache with triage acuity level 3. Further review of Patient #12’s medical record revealed Patient #12 was transferred to another facility on 07/08/2025 at 5:16 PM. Review of Patient #12’s vital signs revealed the following: 07/08/2025 at 10:41 AM Temperature 98.3, Pulse 105, Respirations 20, BP 109/55, Pulse oximeter 100% room air, and pain was not assessed 07/08/2025 at 11:00 AM Pulse 90 07/08/2025 at 1:04 PM Pulse 99 and BP 103/56 07/08/2025 at 4:12 PM Pain 4/10 07/08/2025 at 4:38 PM Pulse 103 07/08/2025 at 4:39 PM Temperature 98.3, Respirations 17 and BP 128/65 07/08/2025 at 5:10 PM Temperature 98.4, Pulse 104, Respirations 18, BP 118/58, Pulse oximeter 99% room air, and pain not assessed In an interview on 07/10/2025 at 3:20 PM, S3SDQPS confirmed the above mentioned findings. S3SDQPS also verified that Patient #12 was an acuity level 3 so per policy blood pressure, pulse, respiratory rate, O2 saturation, and pain should be documented every 2-4 hours while in the ED and at discharge. 2)Failure of nursing staff to document reassessments per hospital policy for 4 (#1, #5, #12, #15) of 20 (#1-#20) patient medical records reviewed. Patient #1 Review of Patient #1’s medical record revealed Patient #1 presented to the ED on 05/15/2025 at 1:22 PM for vaginal bleeding and abdominal cramping. Patient received Tylenol Extra Strength 1000mg by mouth for pain at 8:34 PM. Patient #1 was discharged home at 8:42 PM with no assessment of pain. Patient #5 Review of Patient #5’s medical record revealed Patient #5 presented to the ED on 05/24/2025 at 3:33 PM for vaginal bleeding and abdominal cramping. Patient received Ibuprofen 800mg by mouth for pain. Patient #5 was discharged home at 5:37 PM with no assessment of pain. Patient #12 Review of Patient #12’s medical record revealed Patient #12 presented to the ED on 07/08/2025 at 10:29 AM for vaginal bleeding. Patient #12 received Tylenol Extra Strength 1000mg by mouth for pain 4/10. Patient #12 was transferred to another facility at 5:16 PM with no reassessment of pain. Patient #15 Review of Patient #15’s medical record revealed Patient #15 presented to the ED on 06/19/2025 at 4:26 AM with vaginal bleeding. Patient #15 complain of pain 10/10 at 6:22 AM and received Toradol at 6:27 AM. Patient #15 was discharged at 6:40 AM with no reassessment of pain.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 48050 Based on observation and interview, the hospital failed to ensure signs were posted conspicuously in places likely to be noticed by all individuals entering the emergency department (ED) specifying the rights of individuals under section 1867 of the Emergency Medical Treatment and Active Labor Act (EMTALA), with respect to examination and treatment for emergency medical conditions and women in labor, and to post conspicuously information indicating whether or not the hospital participated in the Medicaid program under a State plan approved under Title XIX. The hospital did not have EMTALA signage posted in the ambulance entrance and ED entry way from a public hallway that leads to other hospital departments. Findings: On 07/09/2025 between 9:26 AM to 9:57 AM, a tour of the emergency department with S1EDD was conducted. The tour revealed there was no EMTALA signage in the following entryways to the emergency department: “ Ambulance Entrance “ ED entry way from a public hallway that leads to other hospital departments. In an interview on 07/09/2023 at 9:38 AM, S1EDD verified there was no EMTALA signage in the ambulance entrance to the emergency department and entry way from public hallway that leads to other hospital departments and there should have been.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice is evidenced by failing to provide an appropriate screening medical exam for 2 (#3, #18) of 20 (#1- #20) reviewed medical records of patients who presented to the emergency department for evaluation (see findings tag A-2406).”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 44495 Based on record review and interview, the hospital’s emergency department failed to provide an appropriate medical screening exam for 2 ( #3, #18) of 20 (#1- #20) patients who presented to the emergency department for evaluation. Findings: Review of Policy #400, Emergency Medical Treatment & Labor Act (EMTALA), revised 01/1014, revealed in part: IV. Definitions: . . . g. Emergency Medical Condition: means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonabley be expected to result in: a. Placing the health of the patient (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; b. Serious impairment to bodily functions, or c. Serious dysfunction of any bodily organ or part; or d. With respect to a pregnant woman who is having contractions: -that there is adequate time to effect a safe Transfer to another hospital before delivery; or -That Transfer may pose a threat to the health or safety of the woman or the unborn child. Review of Policy #ED.316, Assessment of Patients in ED, revised 06/2021, revealed in part, 3. If a bed is not available in the main ED after triage and it is not possible to move the patient directly to the treatment area, the patient may be placed in the waiting area...Patients in the waiting room will be re-evaluated for change or detoerioration of condition at a mimimum of every one hour with documentation in the Electronic Health Record (EHR): vital signs should be repeated every 2 hours and at discharge... Patients in the waiting room should be reassessed hourly; this may be done using the across the room method, with vital signs being obtained every two hours. Patient #3 Review of the emergency department record for Patient #3 revealed she presented to the emergency department on 03/14/2024 at 6:06 a.m. with a chief complaint of migraine headache. Her vital signs were temperature of 98.3° F, pulse 89, Resp 16, BP 168/93, 98%. Review of the provider’s note dated 03/14/2024 at 6:47 a.m. revealed in part: History Chief Complaint - Migraine Patient #3 is a 64-year-old female with a history of obesity, HTN, diabetes, hyperlipidemia and migraines who presents complaining of a migraine that has been intermittent for the past two months. She states that she has seen her neurologist and has been prescribed some new medications but she did not attempt to take anything at home this morning prior to coming to the ER. She endorses nausea, denies any vomiting, She states that she feels like she is going to pass out. This is consistent with prior migraines. . . . Review of Systems Physical Exam Blood pressure (1) 168/93, pulse 89, temperature 98.3°F (36.8°C)x, temperature source Oral, resp .rate 16, SpO2 98%. BP Method: Automatic BP Location: Left arm Physical Exam Vitals and nursing note reviewed. Constitutional: General: She is not in acute distress. Comments: Appears comfortable HENT: Head: Normocephalic and atraumatic. Eyes: General: No scleral icterus. Right Eye: No discharge. Left Eye: No discharge. Neck: Trachea: No tracheal deviation Pulmonary: Effort: Pulmonary effort is normal. No respiratory distress. Breath sounds: No stridor Abdominal: General: There is no distention. Musculoskeletal: General: No deformity. Normal range of motion. Cervical back: neck supple Skin: General: Skin is warm and dry Neurological: Mental Status: She is alert and oriented to person, place and time. Psychiatric: Behavior: Behavior normal Procedures Medical Decision Making Differential diagnosis includes migraine, tension headache Further review of the medical record revealed at 6:41 a.m. the patient was given 1,000 milliliters of 0.9% sodium chloride I.V., droperidol 2.5 milligram I.V., and diphenhydramine 50 milligrams I.V. At 6:42 a.m. the patient received ketorolac 15 milligrams I.V. Reassessment of her pain at 7:17 a.m. revealed the patient was no longer experiencing pain and repeat vitals at 7:28 a.m. were normal. The patient was discharged at 9:29 a.m. In interview on 04/09/2024 at 12:55 p.m. S1DQ verified there were not laboratory studies and no imaging studies performed on Patient #3. In interview on 04/10/2024 between 9:29 a.m. and 9:33 p.m., S4MD was allowed to review the medical record. S4MD verified that patients presenting with migraine headaches should receive a through neurologic examination and more detail was needed in the documentation for this patient. Patient #18 Review of the emergency department record for Patient #18 revealed the patient was a 3 month old infant with a history of atrial flutter who was brought to the emergency department on 04/05/2024 at 9:27 p.m. for evaluation after a motor vehicle collision. The patient was assessed as ESI Acuity Level 5. The patient’s medications at home included Vitamin D3, propranolol, and digoxin. Review of the provider’s note from 04/05/2024 at 10:05 p.m. revealed in part: History Chief Complaint - Motor Vehicle Crash 3 mo M PMHx atrial flutter presents to the ED for MVC x yesterday. Patient was the restrained back seat passenger of his mother’s vehicle. Patient in his car seat starting accident. Rear-ended at low speed, No airbag deployment. Patient’s mother just wants patient to be evaluated to make sure he is okay. Patient is still acting normally. . . . Blood pressure . pulse , temperature source , resp. rate , Sp02 . Physical Exam Vitals and nursing notes reviewed. Constitutional: General: He is irritable. He is not in acute distress. Appearance: Normal appearance. He is well-developed. He is no toxic- appearing. HENT: Head: Normocephalic and atraumatic. Anterior fontanelle is flat. Nose: Nose normal. Mouth/Throat: Mouth: Mucous membranes are moist. Pharynx: Oropharynx is clear. Eyes: General: Red reflexes is present bilaterally. Extraocular Movements: Extraocular movements intact. Conjunctiva/sclera: Conjunctivae normal. Pupils: Pupils are equal, round, and reactive to light. Cardiovascular: Rate and Rhythm: Normal rate and rhythm. Pulses: Normal pulses. Heart sounds: Normal heart sounds. Abdominal: General: Abdomen is flat. Palpations: Abdomen is soft. Musculoskeletal: General: Normal range of motion. Cervical back: Normal range of motion and neck supple. Skin: General: Skin is warm and dry. Capillary Refill: Capillary refill takes less than 2 seconds. Turgor: Normal Neurological: General: No focal deficit present. Mental Status: He is alert. Procedures Medical Decision Making Ddx: MVC 3-month-old male seen here today for MCV. Vital signs are stable nontoxic appearing. Physical examination unremarkable. Advised patient to follow-up with pediatrician and instructions to go to Children’s ER with new or worsening symptoms. The patient was discharged to home on 04/05/2024 at 10:05 p.m. In interview on 04/09/2025 at 2:48 p.m., S1DQ verified vital signs were not taken on the patient. In interview on 04/10/2024 at 8:18 a.m., S6RN verified the infant was sleeping when he went to take the vital signs and he did not want to awaken the infant and forgot to take the vitals when the infant woke up.”