HospitalInspections.org

Based on staff interviews and document review, the acute care hospital's administrative staff failed to ensure the Emergency Department (ED) staff did not destroy the documentation for 1 of 1 patients (Patient #1) who required monitoring to ensure the patient did not harm themselves in the ED. Failure of the ED staff to retain documentation could potentially result in the nursing staff failing to identify changes in a patient's behavior and potentially failing to identify the warning signs of a patient who could harm themselves. The hospital's administrative staff identified that approximately 5,400 patients sought emergency medical care at the ED per month.

Findings include:

1. Review of the policy "Documentation in the Medical Record" revealed in part, "The purpose of the documentation in the medical record is to ... provide evidence of the course of the patient's evaluation, treatment and response to treatment, facilitate communications between the responsible practitioner and other health professionals ..."

2. During an interview on 6/6/22 at 10:30 AM, Patient Companion A revealed they observed patients in the ED and ensured that the patient did not attempt to harm themselves, such as attempting to commit suicide in the ED. Patient Companion A verified they observed Patient #1 during Patient #1's ED visit to ensure Patient #1 did not attempt to harm themselves in the ED. Patient Companion A documented their observations of Patient #1's behavior on a paper form.

3. Review of Patient #1's medical records revealed that Patient #1's medical record lacked the document that Patient Companion A utilized to document Patient Companion A's observations of Patient #1's behavior during Patient #1's ED visit.

4. During an interview on 6/7/22 at 2:15 PM, the Director of Nursing for the ED verified the Patient Companions documented their observations of their supervised patients on a paper form. The Director of Nursing for the ED indicated that the Patient Companions include the paper for with their documentation of the patient's behaviors in the paper portion of the patient's medical record. The medical records staff normally scanned the patient's paper medical record documentation, including the documentation created by the Patient Companions, into the patient's permanent electronic medical record.

The Director of Nursing for the ED verified that the paper documentation Patient Companion A created to document Patient #1's behavior during the ED visit was not in Patient #1's medical record. The Director of Nursing for the ED indicated that the documentation was accidentally destroyed and that was the reason why Patient Companion A's documentation did not go into Patient #1's electronic medical record.