HospitalInspections.org

Based on interviews and record reviews the hospital failed to maintain a medical record for a patient. Specifically, A) the hospital did not document an incident of a Code Down being called in the patient's medical chart B) the hospital did not properly complete the patient's Emergency Services Release of Responsibility form.


This failure has the potential to affect all patient's records from being accurately written, promptly completed, properly filed and retained, and accessible.


Findings include:


A)
Review of Patient #1's complete medical record revealed no mention of an incident of him leaving the Emergency Department (ED) waiting room and fainting in the hospital parking lot on 02/21/2014, which resulted in a Code Down being called.

In an interview with Staff #1, on 5/6/14 at 1:45 PM, he was asked about his interaction with Patient #1 and his mother on the evening of 2/21/14. He stated, "I remember [Patient #1] and his mother coming in. It was a very busy night for us, a Friday night. We had a full house with people in the waiting room, waiting to be triaged. [Patient #1] presented with migraine symptoms. He didn't say anything; his mother did all the speaking for him. Shortly after checking in the mother asked about the wait. I told them they would be triaged by presenting symptoms and severity of symptoms. I remember the mother becoming increasingly agitated."

Staff #1 stated that he informed the triage nurse of any reports the mother made regarding her son's symptoms. "She was saying 'he's being waiting' and any other complaints I relayed the information to the triage nurse behind me .... She (Patient #1's mother) became agitated: yelling, saying derogatory things towards staff and the hospital. She stated she wanted to leave. I asked if she wanted to be taken out of the triage list. I took them out of the list. I saw them walk out. The son walked out of the waiting area."

"So [Patient #1] and his mother left and maybe a minute later she came running back through the doors yelling at me with vulgar names, stating that we killed her son. I asked her what happened. She said, 'He's dead. He passed out in the parking lot.' I told the triage nurse behind me we possibly had a patient down outside."

According to Staff #1, when he arrived on the scene near the sidewalk entrance to the Emergency Department he found Patient #1, "Supine in grass. Coherent, alert, and got him to sit up ....He was supine flat on his back and had his eyes closed when I approached him. I shouted his name he opened his eyes and I asked him, 'what happened?". He said he didn't know. I asked him orientation questions and he answered appropriately. He was alert and oriented. He wasn't in any altered level of consciousness."

"During the whole encounter in the parking lot the mother was very irrational and aggressive. While we were trying to assist her son into a wheel chair. An APD officer intervened and isolated the mother way from the area while we got the son back into the ER. We took him into the acute area and I passed off the care of him to the nurses."

In an interview with Staff #5 on 5/6/14 at 2:05 PM, she assisted in reviewing the physician documentation in the ED record. She confirmed that more detail should have been documented. She confirmed that no documentation of the code down was in the ED record, the only documentation of the event was in separate incident reports. She stated, "I told the nurse's they did a good job charting, just not in the right place."

She also acknowledged that there was no nursing documentation of the patient leaving the facility AMA (Against Medical Advice).

In an interview with Staff #3 on 5/6/14 at 2:25 PM she confirmed she was the charge nurse from 7 AM through 7 PM on 2/21/14. She was asked about her interactions with Patient #1 on 2/21/14. She replied, "It was one of my last shifts in a clinical role. I was in charge that evening. What I remember is we were extremely busy that night. All my rooms were full."

"I know for certain he had been registered but not triaged. He was soon to be triaged; I came in contact with him (Patient #1) after the incident where the mother was very vocal in the waiting room. By the time I go there they had exited the building. I know they exited the building and the code down was called and he came back into the unit."

Review of the facility's Professional Relations Incident Report dated 02/21/2014, read, " Patient #1 entered the ED at 6:10 pm with his mother. Mother unhappy had to wait and felt son should be seen immediately. Patient #1 and family decided to leave 2 minutes before being called back to be seen in ED. Patient #1 observed leaving first and code down in parking lot sidewalk, appropriate response by staff with Patient #1. Mother claims Patient #1 passed out, staff relate Patient #1 alert and able to stand and get in wheelchair. Mother irate believing patient should have been taken straight back using foul language in parking lot, continued verbal attack in waiting room. Police/security and house supervisor involved with mother to calm her, she remained angry. Mother threatened if she could not see her son in the ED she would leave and take her son to another hospital. Attempts to explain reasons why she was not allowed to see her son, but it did not matter. She continued talking loudly on her cell phone in the ED lobby to an unknown person saying derogatory remarks about ED greeter, and the hospital as a whole, and asking the person she was talking to for a good lawyer. Patient #1 in the ED was informed of his mother being upset and threating to go to another hospital, if she couldn't see him. He decided to leave against medical advice (AMA). AMA papers were signed."


Review of the facility's Event Reporting Incident Report dated 02/22/2014, revealed on 02/21/2014 at 6:45 pm, the evening security guard observed a female screaming in the ED parking lot. Security guard saw Patient #1 on the ground, and quickly rushed over to him with a wheelchair, and assisted him up. In about 2 seconds a nurse and an Austin Police Department officer came to assist Patient #1. Patient #1 was taken to acute care for treatment. He was not unconscious when staff members picked him up from the ground. The mother was not allowed to go inside the ED because she was acting unprofessional. She was yelling and screaming saying she was going to sue everyone. The mother stated that they left the hospital because nobody attended to her son after waiting in the ED waiting room for an hour. [Staff #1], stated that he explained to the mother and the son that the nurse was busy with other patients. Patient #1 wanted his mother to go in the ED with him, but he was explained his mother needed to calm down first because we have other patients in the ED. Patient #1 said he wanted to be discharged, at 7:50 pm the patient was discharged and they left the hospital.


Review of another facility's Event Reporting Incident Report dated 02/22/2014, revealed Patient #1 was checking into the ED for a headache and was waiting for an assessment by the triage nurse. The triage nurse watched Patient #1 ambulating with a steady gait. Patient #1's mother became very upset that Patient #1 was not taken back to the ED quickly. Patient #1's mother started yelling at the ED greeter and cursing loudly. Patient #1 walked outside as this was happening and mother continued to yell, but then went outside. A code down was called because apparently Patient #1 fainted and fell in the parking lot. Patient #1 was brought into an acute room. Patient #1's mother continued to yell and curse at nurses trying to take Patient #1 in and she was not allowed back to the ED room until she calmed down. Patient #1 then decided to sign out AMA, because his mother could not come back immediately.


B)

Review of Patient #1's Emergency Services Release of Responsibility dated 02/21/2014 revealed it was not signed by a Registered Nurse, and the documentation criteria was left blank.

In an interview with Staff #5 on 5/6/14 at 2:05 PM, she assisted in reviewing the physician documentation in the ED record. She confirmed that more detail should have been documented.

She also acknowledged that there was no nursing documentation of the patient leaving the facility AMA (Against Medical Advice) and that the AMA form was incomplete.

Facility based policy entitled, "Leaving Against Medical Advice (AMA) from Emergency Services" stated in part,

"Required Forms
Release of Responsibility Form (English and Spanish forms available) ...

Documentation
The Emergency Department RN/LVN will document the following criteria on the Release of Responsibility form:
? AMA form signed or refusal to sign noted
? Patient assured of medical care in the facility
? Patient instructed/understands to seek timely medical care
? Patient's plan to seek medical attention
? Condition of patient
? Patient advised of risk of leaving AMA
? MD notification documented for patient leaving after MD evaluation
Form/Document Title
Release of Responsibility Form

Usage
Instructions
Documentation will include checking the appropriate boxes, which includes facility location, and a short, thorough entry in the nurse's notes addressing the fact that these criteria were discussed with the patient/legal guardian and the patient/legal guardian voiced understanding of the criteria."


Facility based policy entitled, "Documenting of Patient Care on ED Record" stated in part, "The nurse responsible for the discharge or transferring the patient from the ED will be responsible for documenting the final disposition of the patient ...
5. The nurse responsible for discharging or transferring the patient from the ED, will document final disposition of the patient, patient condition at the time of transfer/discharge and any teaching and referral information in the discharge summary on page two on the Emergency Department record or the appropriate sections of the electronic chart. He/she will sign in the "Disposition Nurse Signature" box."