HospitalInspections.org

Based on interview and inspection, it was determined that the facility failed to follow it's own policy in regard to reporting animal bites.

Findings were:

Facility policy entitled "Animal Bites Reporting" stated in part "Animal bites are required to be reported to the state health department or animal control following a detailed report and treatment."

On 7/12/21, patient # 15 was seen in the ED after being bitten by a cat. There is no documented evidence that the bite was reported to City or County Law enforcement.

The Director of Nurses confirmed the lack of notification to City or County law enforcement on the morning of 5/16/23.

Based on record review and interview the facility failed to ensure that the medical record was accurately documented. The facility failed to ensure that the medical record reflected the "No Code" physician order.

Findings were:
Review of Patient #10's medical record reflected that she was admitted on 2/24/23 with a diagnosis of Stroke. Review of the patient medical record reflected a "Full Code Status". Further review of the Specified Resuscitation Order dated 2/24/23 reflected "No Code" as the order.
Review of the facility policy "Do Not Resuscitate, effective 6/7/22, reflected: "... Document, in each inpatient's electronic medical record, whether or not the patient has executed an advance directive, medical power of attorney, or issued directions regarding the attempt of cardiopulmonary resuscitation after cessation of the circulatory or respiratory functions orally or in writing..."
During an interview on the morning of 5/17/23 Staff #13 reported that "the Code Status should have been updated in the computer."

Based on observation and interview, the facility failed to post the Emergency Medical Treatment and Active Labor Act (EMTALA) signage in the emergency department ambulance entrance.

Findings included:

An observation of the facility's emergency department ambulance entrance, on the morning of 5/17/23, revealed there was no EMTALA signage.

During an interview on the morning of 5/17/23, in the facility's emergency department ambulance entrance, Staff # 17, CNO, confirmed patients come in to this entrance and that the signage was missing.