HospitalInspections.org

Based on review of hospital policies/procedures, documents, the target medical record, and interviews, it was determined that the hospital failed to correctly identify one (1) of one (1) patient who presented to the Emergency Department (ED) in full code arrest, who subsequently expired (Patient #1), before notifying the wrong family/representative of the death.

Findings include:

The hospital policy titled Patient Identification (last reviewed 09/2010), requires: "...two (2) identifiers are patient name and patient birth date to ensure the correct patient is involved...."

The Admitting/Registration "shared document" titled SMARTIES (Success Manual Active Registration Training In Every Situation) on the hospital's computer system and available to employees, requires: "...Code/ALOC (altered level of consciousness) Registration Tips...If the patient's identity is unknown at the time of registration...Enter the patient's name as John/Jane Doe...Enter the DOB (date of birth) as 1/1 and approx. (approximately) year for age estimate...Information will need to be updated as it becomes available...."

The Emergency Medical System (EMS) brought Patient #1, to the ED on 02/27/14 at 0411, unresponsive, asystolic, and in full code arrest. According to the medical record (EMS Report) the patient was without identification, however, a prescription inhaler was found "near by" and the EMS took the name from the inhaler to tentatively identify the patient. Upon arrival to the ED, the patient was admitted/registered under the name on the inhaler, which provided demographics ("Face Sheet") as the patient had been seen in the ED in the past and the computer retained the information. The ED attempted resuscitation, however; the patient was pronounced dead at 0419. The hospital notified the next of kin listed on the Face Sheet, who visited, viewed the body, and notified the hospital that the decedent was misidentified.

Upon entering the hospital on 03/03/14, the surveyors requested and received the ED log for 02/27/14. The mis-identified patient was offered to the surveyors without prompting, during review of the log.

Interviews were conducted with three (3) ED Admission/Registration staff during a tour of the ED on 03/03/14 from 1410 through 1445. One (1) of the three (3) personnel could not verbalize the current protocol for Registration of an unresponsive patient who presents without family or identification (ID), as follows:

Registration Clerk #9, offered that s/he takes information from the ambulance "run sheet" for identification of the patient. The other two (2) ED registration clerks explained they would use the ambulance run sheet for ID, unless there was another government issued ID with a picture. If no ID were with the unresponsive patient, the registration clerks explained the patient would be entered into the hospital's computer database as "John Doe or Jane Doe."

The Director of Quality/Risk Management, and the Chief Nursing Officer confirmed during interviews conducted 03/03/14 - 03/04/14, that the ED staff did not follow the hospital's process for identifying an unresponsive patient that presents to the hospital without proper identification or next of kin.

The Chief Nursing Officer and Quality Director confirmed on 03/03/14, at 1345 hours, the hospital had not provided education to staff regarding patient identification, but, they had discussed an action plan that was being developed and was to be implemented soon.

The hospital did not follow their policies/processes for correctly identifying the patient before contacting the next of kin.