HospitalInspections.org

32177

A. Based on review of the medical records, documents and staff interview it was determined that the Critical Access Hospital (CAH) failed to provide emergency care per acceptable standards/policy for two (2) of two (2) patients reviewed (patient #11 and patient # 12) who presented to the Emergency Department with alcohol intoxication. This failure creates the potential for the care and condition of all patients with alcohol intoxication to be adversely impacted. Findings include:

1. Review of the Emergency Department (ED) record for patient #11 revealed the patient presented to the ED on 04/12/13 and was triaged at 2114. The record revealed the Chief Complaint/Reason for Visit was Chest Pain/Back Pain. The record reflected ED Physician #1 ordered multiple laboratory tests. At 2135 a blood alcohol level of 350 mg/dl (milligrams per deciliter) was reported, with 0-10 mg/dl noted as the normal reference. The lab report noted Coma may appear with an alcohol level of 300 mg/dl. The Physician recorded the Clinical Impression as Acute Alcohol Intoxication and Acute Abdominal Pain. The medical record revealed the patient was discharged home at 2322. The record revealed no repeat blood alcohol level prior to discharge. Review of discharge instructions revealed these were signed by the patient. The record lacked a signature of, or any mention of a responsible adult who was to drive the patient home.

2. Review of the hospitalwide "Emergency Medical Treatment and Active Labor Act," policy, last reviewed 12/12, revealed it states in part: "Abnormal findings should be normalized via treatment and documented by serial values or explained away prior to discharge."

3. The 2/19/13 Plan of Correction (POC) submitted by the CAH was reviewed. The POC states in part: "The ED Medical Director did send a memo on 01/25/13 reminding all ED physicians about the required documentation that needs to be in the medical record." The POC also states the ED Medical Director will review five (5) charts per full-time physicians for physician documentation for three (3) months. The completion date for this chart audit was recorded as 3/31/13.

4. At approximately 1000 on 4/15/13 the Executive Director of Quality stated the ED Medical Director had not yet completed the chart audit as noted in the POC.

5. Review of the 1/25/13 memo sent by the ED Medical Director revealed it stated in part: "Patients found to have abnormal results in their medical work up which could be consistent with the possibility of causing serious bodily harm to themselves or others, if left unaddressed by the physician, should have documentation of why the abnormal results were not medically addressed. For example, a person suffering from alcoholism found to have a blood alcohol level of 350 should have documentation pertaining to the patient's chronic ethanol abuse, with subsequent relative biological tolerance to the elevated ethanol level, and the patient is not to drive from the facility at the time of discharge."

6. This record was reviewed and discussed with the Executive Director of Emergency Nursing Services at 1000 on 4/17/13. She agreed with these findings.

7. This record was reviewed and discussed with the CAH Chief of Medical Staff on 04/17/13 at 1155. He concurred the record lacked documentation of a repeat alcohol level or documentation of a responsible person to drive the patient home. After review of the above 1/25/13 Memo the Chief of Medical Staff acknowledged the record lacked the physician documentation as required and directed by the memo.

8. Review of the ED record for patient #12 revealed the patient arrived at the ED by ambulance on 4/15/13 and was triaged at 0409. The record revealed the Chief Complaint/Reason for Visit was noted as: "Passed out, light headed/dizzy, chest pain, SOB (shortness of breath), and HA (headache).

9. A blood alcohol level of 228 mg/dl was obtained at 0411, with >100 mg/dl indicating Intoxication. The physician recorded the Clinical Impression as: "Syncope and ETOH (alcohol) intox." The ED record revealed the Disposition as: "Home" and "Stable". The only orders written for discharge were "D/C home. Rest. Fluids." The patient signed her discharge instructions and was discharged at 0626.

10. Review of the ED record for patient #12 revealed no repeat blood alcohol level prior to discharge. The record also contained no order or physician documentation to reflect the patient was not to drive from the facility at the time of discharge.

11. The policy "Emergency Medical Treatment and Active Labor Act," last reviewed 12/12 was provided for review. It states in part: "Abnormal findings should be normalized via treatment and documented by serial values or explained away prior to discharge."

12. The 2/19/13 Plan of Correction submitted by the CAH was reviewed. The plan includes the statement "The ER Medical Director did send a memo on 1/25/13 reminding all ER physician's about the required documentation that needs to be in the medical record."

13. Review of the 1/25/13 memo reveals it states in part, "Patients found to have abnormal results in their medical work up which could be consistent with the possibility of causing bodily harm to themselves or others, if left unaddressed by the physician, should have documentation of why the abnormal results were not medically addressed...and the patient is not to drive from the facility at the time of discharge."

14. This record was reviewed and discussed with the CAH Medical Chief of Staff on 4/17/13 at 1155. He stated the decision for no repeat blood alcohol level was a clinical judgement on the part of the ED physician. He agreed the record lacked documentation to explain this clinical judgement other that the marking of the "stable" box on the Emergency Physician Record. He also acknowledged there was no order to prevent the patient from driving at the time of discharge. He stated "I don't think the doctor followed the memo in this case".

B. Based on review of the medical records, documents and staff interview it was determined that the Critical Access Hospital (CAH) failed to provide emergency care per acceptable standards/policy/state law for one (1) of one (1) patients reviewed who reported abuse while in the the Emergency Department (patient #4). The CAH failed to contact the Department of Health and Human Services (DHHS) as required per policy. This failure creates the potential for the care and condition of all patients who are victims of abuse to be adversely impacted.

Findings include:

1. Review of the ED record for patient #4 revealed the patient presented to the ED on 04/07/13 and was triaged at 1722. The record reflected the Registered Nurse (RN) recorded the Chief Complaint as Chest Pain. The record revealed that at 1722 the nurse documented: "altercation with daughter four (4) days ago,"yet recorded "NO" to the question" "Do you suspect abuse or neglect?" Further review of the record revealed that at 1725 the Nurse documented the Chief Complaint/Reason for Visit as: "Chest Pain/Assault 4 days ago." The nurse also documented the patient as tearful during triage and assessment.

The record lacked any documentation to reflect a referral/report related to the abuse was made to the proper authorities, as required. The record reflected the patient was discharged home at 1900.

2. The Policy "Suspected Abuse of an ED Patient," last revised 12/06, was provided for review. The policy states in part: "When the nurse or physician suspects that the patient may be a victim of abuse, he/she will contact the Department of Health and Human Service (DHHS) to file a report."

The Policy "Disclosures of Protected Health Information About Victims of Child Abuse, Other Abuse, Neglect, or Domestic Violence," last reviewed 5/30/12, was provided for review. It states in part: "Roane General Hospital will comply with applicable state laws that require health care providers to report suspected case of abuse or neglect of children or adults, other forms of domestic violence (collectively 'abuse reporting laws')."

3. This record was reviewed and discussed with the Executive Director of Emergency Nursing Services at 0935 on 4/17/13. She concurred the record lacked documentation that a report regarding the suspected abuse was made to DHHS as required.

4. This record was reviewed and discussed with the CAH Chief of Medical Staff on 04/17/13 at 1255. He concurred the record lacked documentation that a report regarding the suspected abuse was made to DHHS as required.

C. Based on record review, document review and staff interview it was determined the CAH failed to provide emergency care per acceptable standards for one (1) of two (2) patients reviewed (patient #4) who presented with Chest Pain. The ED physician failed to document a review of laboratory results and vital signs. This failure creates the potential for the care of all patients with chest pain to be adversely impacted.

Findings include:

1. Review of the ED record for patient #4 revealed the patient presented to the ED on 04/07/13 and was triaged at 1722. The record reflected the RN recorded the Chief Complaint as Chest Pain.

2. The record reflected that ED Physician #2 ordered multiple laboratory tests. The ED physician documented the patient was seen at 1752. Review of the Emergency Physician Record revealed the physician failed to document a review of the patient's laboratory results and vital signs.

3. This record was reviewed and discussed with the CAH Chief of Medical Staff on 04/17/13 at 1255. He concurred that the physician failed to document a review of the patient's laboratory results and vital signs in the ED Physician Record as expected.

4. Review of the 2/19/13 POC reveals it states the ED Medical Director will review five (5) charts per full-time physicians for physician documentation for three (3) months. The completion date for this chart audit was recorded as 3/31/13.

5. At approximately 1000 on 4/15/13 the Executive Director of Quality stated the ED Medical Director had not yet completed the chart audit as noted in the POC.

D. Based on review of the medical records, documents and staff interview it was determined that the Critical Access Hospital (CAH) failed to provide emergency care per acceptable standards/policy for one (1) of one (1) patients reviewed who presented to the Emergency Department requesting treatment for Drug Abuse (patient #3). The ED failed to provide medical clearance before the patient was discharged for admittance to an inpatient treatment facility for heroin abuse. This failure creates the potential for the care and condition of all patients with substance abuse to be adversely impacted.

Findings include:

1. Review of the ED record for patient #3 revealed the patient presented to the ED on 04/07/13 and was triaged at 1404 with the Chief Complaint recorded as Drug Abuse. The record revealed the patient has been addicted to heroin for one (1) year and wanted to be admitted to an inpatient substance abuse unit for treatment. The record reflected the patient's last heroin use occurred at 0300, approximately eleven (11) hours prior to arrival in the ED. A review of laboratory testing, ordered while the patient was in the ED revealed the patient did test positive for the presence of heroin.

The record reflected a consult for inpatient treatment was initiated and an inpatient psychiatric treatment facility accepted the patient. Review of the Emergency Physician Record revealed the "Medical Clearance For Psychiatric Referral" section was not completed. The physician recorded the Clinical Impression as Heroin Addiction and the record reflected the patient was discharged by personal vehicle to the psychiatric facility for treatment at 1841.

2. The 2/19/13 POC submitted by the CAH was reviewed. The plan includes the statement: "The ED Medical Director did send a memo on 01/25/13 reminding all ED physicians that medical clearance needs to always be documented."

3. A review of the 1/25/13 Memo revealed it states in part: "Regarding interactions with psychiatric and/or substance abuse patients, several components need to be consistently documented on the T-sheet. Medical clearance needs to always be documented (when pertinent)."

4. This record was reviewed and discussed with the Executive Director of Emergency Services on 04/17/13 at 0935. She concurred no medical clearance was completed on this patient.

5. This record was reviewed and discussed with the Chief of Medical Staff on 04/17/13 at 1225. He concurred that no medical clearance was completed on this patient.


32417


E. Based on review of medical records, review of documents, and staff interview, it was determined the CAH failed to provide emergency care per acceptable standards/policy for one (1) of one (1) patients reviewed (patient # 9) who presented to the Emergency Department with a closed head injury. The ED failed to ensure vital signs were rechecked and discharge instructions were complete and provided per policy. This failure creates the potential for the care and condition of all patients to be adversely impacted.

Findings include:

1. Review of the Emergency Room record for patient #9, age 11, revealed the patient present to the ED on 4/12/13 at 0955. The Chief Complaint/Reason for Treatment was noted as: "patient was running and hit his head against wall". The record reflected the vitals signs were checked once at triage and the patient received Tylenol. The physician recorded the Clinical Impression as: "Closed Head Injury". The ED physician's orders at discharge stated "Tylenol given. D/C home... Return for development of confusion, vomiting." The patient received written discharge instructions which were signed by the legal guardian. The patient was discharged at 1011.

Review of the Discharge Instructions provided revealed no instructions for the patient to return for confusion or vomiting as ordered by the physician.

2. Review of the ED Discharge Policy, effective 4/22/10, revealed, in part, "All patients in the ED will have discharge vital signs with the exception of patients with a length of stay less than 30 minutes whom have not received any medications and vital signs were stable upon arrival."

3. This record was reviewed and discussed with the Executive Director Emergency Nursing Services on 4/17/13 at 1110. She agreed the patient had received medication and vital signs had not been rechecked prior to discharge.

4. Review of ED Discharge Policy, effective 4/22/10, revealed, in part, "Complete the patient's information and attach appropriate instructions in ExitCare and print the packet (see Exit Care policy)".

Review of Patient ExitCare policy, last reviewed 4/11, revealed in part, under "Key Points: Print the head injury education sheet for any patient suffering from a head injury and being discharged."

5. During interview with the Executive Director of Emergency Nursing Services on 4/17/13 at 1110, these written discharge instructions provided to the patient were reviewed and discussed. She agreed the record lacked instructions for return for development of confusion, vomiting. She also agreed the record lacked a copy of a head injury education sheet, or any indication that a head injury education sheet had been provided to the patient/guardian at discharge.

6. The 2/19/13 POC, submitted by the CAH related to Condition level deficiency cited related to Emergency Services revealed it states in part: "Also beginning in January, 10% of ED charts will be audited by the Executive Director of Emergency Services for nursing vital sign documentation compliance for three (3) months. The completion date for this audit was noted as: 3/31/13. During the above interview with the Executive Director she confirmed she had only completed the January ED chart audit and had not yet completed the audits for February and March.

Based on observations and interview during a revisit conducted at Roane General Hospital on 04/15/13, it was determined the facility failed to complete tags K071 as listed in the plan of correction. Therefore, the condition is not met.