HospitalInspections.org

Based on review of the Emergency Room Log and interviews the hospital failed to maintain an accurate record of the patients seeking medical care as evidenced by: 1) incomplete entries; 2) late entries of patients who had left without being seen; and 3) use of undefined terms relating to patients not being treated resulting in the hospital's inability to determine if the patient had been treated or the disposition of the untreated patient. Findings:

1) incomplete entries;
Review of the Emergency Department Log currently used by the hospital revealed the following information was required to be documented: Date; Time; AM or PM; Patient's name; Address; Age; M or F (Male or Female); Nurse/Physician Assistant; Physician; Emergency Room Number; Nature of Illness; whether it was an Emergency or Non-emergency, Treatment Refused, Did Not Treat; Reason; Admitted; Stabilized/Transferred; Name of Receiving Facility; Treated & Discharged, Time, AM or PM, Instructions Provided/Explained.

Review of the Emergency Department Log dated 11/01/11 through 05/21/2012 revealed the following information was not documented on any entry as required by the log: whether or not the patient was emergent or non-emergent; if treatment was refused or he/she was not treated; and whether the patient was admitted or was stabilized and transferred.

Review of the policy and procedure manual for the Emergency Department submitted as the one currently in use revealed no documented evidence a policy had been developed for the use of the Emergency Room Log.

2) late entries of patients into the log;
Review of the Emergency Room (ER) Log revealed the following entries dated as follows:
02/24/12 14:15
01/27/12 4:34pm
02/17/12 11:12am
02/03/12 5:52pm
02/08/12 5:52pm
02/11/12 4:23pm
02/19/12 12:35pm
02/19/12 4:25pm
02/24/12 15:33
Further review of the ER Log revealed all of the late entries were documented as patients who had LWBS (left without being seen). According to the log, there was no documented evidence at one point in the ER process the patients had left without being seen (i.e. the clerk, triage nurse or MD).

In a face to face interview on 05/23/12 at 3:00pm RN S6 ADON (Assistant Director of Nursing) indicated the clerks were responsible for entering the information into the ER Log. Further S6 indicated when the ER did not have clerk coverage, the nursing staff had the responsibility for keeping up the logs. S6 indicated that at times the ER gets very busy and the two nurses scheduled do not have the time to perform this task, so it is done at a later time by the clerk.

3) undefined terms relating to patients not being treated used by the staff resulting in the hospital's inability to determine an accurate disposition of the untreated patient
Review of the Emergency Department Log dated 11/01/11 through 05/21/2012 revealed the following abbreviations and descriptions used for disposition of the patients: AMA (leaving Against Medical Advise); LWBS (Leaving Without Being Seen); left without signing, deserted, and left prior to triage.

Review of the policy and procedure manual for the Emergency Department submitted as the one currently in use revealed no documented evidence definitions and/or explanations were provided for AMA (Against Medical Advise), LWBS (Leaving Without Being Seen), left without signing, deserted, and left prior to triage. Further review revealed no documented evidence a policy had been developed for the use of the Emergency Room Log.

In a face to face interview on 05/23/12 at 2:15pm RN S2 Director of Nursing verified there were no policies for the use of the Emergency Department Log or definitions/explanations for the meaning of the abbreviations and descriptions used by the nursing staff in documenting the disposition of patients.

In a face to face interview on 05/23/12 at 3:00pm RN S6 ADON agreed it would be difficult to determine at what point the patient left without being seen and if he/she had been triaged. S6 indicated the policies for the Emergency Room do not contain all of the policies needed and are outdated and need revision.

Based on observation, record review and interview the hospital failed to ensure a medical screening was provided to a patient (#10) brought to the hospital via ambulance for a drug overdose as evidenced by the contracted Emergency Room Physician refusing to allow the ambulance personnel to remove the patient from the ambulance upon arrival to the hospital resulting in the patient having to be transported to another hospital to receive treatment. Findings:

Observation on 05/21/12 at 11:00am of the Emergency Department revealed five rooms were used for treatment of patients. Room 1 was used for the psychiatric patients, Room 2 for Critical patients and Rooms 3, 4, 5 for all others diagnoses. According to the ADON RN S6, when the ED had more than one PEC'd patient at a time he/she would be placed in Room 3 directly across from the nurses' station.

Review of the staffing pattern for 04/30/12 7PM shift revealed the following staff was on duty: ED physician, RN Charge Nurse, RN, Registration Clerk. A contracted security guard was stationed in the Emergency Room, but was not there at all times due to other assigned duties inside and outside of the hospital.

Review of the Emergency Room Log dated/timed 04/30/12 11:35am through 11:20pm revealed the following patients were registered and/or remained in the Emergency Department at the time of the ambulance call from Company "A" through the arrival of Patient #10 to the hospital ED;
Patient #1 PEC (Physician's Emergency Certificate) for overdose admitted at 11:35am and discharged 05/01/12 at 0835 (8:35am);
Patient #2 asthma admitted 2129 (9:29pm) left AMA at 2220 (10:20pm);
Patient #3 middle finger I&D (incision and drainage) admitted 2210 (10:10pm) discharged 2320 (11:20pm);
Patient #12 child with a rock up his nose admitted 2200 (10:00am) discharged 2230 (10:30pm); and Patient #11 SOB (shortness of breath) and chest pains arrived at 2205 (10:05) triaged at 22:05 (10:05pm) left without being seen sometime after 10:05pm after being told to have a seat in the waiting room.

Patient #10
Review of Incident #9947448 dated 04/30/12 revealed ambulance Company "A" was called by family members after finding Patient #10 at a hotel in what appeared to be a heavily intoxicated state. The family also had found an empty bottle of the prescription drugs Prozac and Restoril and indicated the patient might have consumed 2 gallons of vodka. Arrival on the scene at 2202 (10:02pm) found Patient #10 sitting on the bed, awake, alert, disoriented, and experiencing difficulty with speech. Oxygen saturation on room air was 90% with a blood pressure of 106/70. Hood Memorial Hospital was contacted and MD S3 Emergency Room physician wanted the patient diverted due to the hospital already having a PEC'd (Physician Emergency Certificate) patient. Oxygen 3l (liters) per nc (nasal cannula) was started. Supervisor of Company "A" notified of the request from Hood Memorial to divert a Status 3 patient. RN S5 notified of a 3 minute eta (estimated time of arrival). Narcan 1mg was administered with no results. Diverted to Hospital "B" (Arrival 2252 (10:52pm).

In a face to face interview on 05/22/12 at 7:25am MD S3 Emergency Room contracted physician for 04/30/12 at 7P indicated he had received a call from Company "A" for an overdose. Further S3 verified the hospital was not on divert; however he asked EMS to divert the overdose because the ED already had one PEC'd patient. In addition, the hospital was having a tough time finding placement for psychiatric patients and they were spending longer periods of time in the ED. S3 indicated when he spoke with EMS the person said "OK" to the diversion so he was very surprised when they showed up at the ED. S3 indicated he met the ambulance and told them they would have to take the patient to another facility but at no time did he use foul language.

Review of the census of the hospital on 04/30/12 at 2232 (10:32pm) at the time of the arrival of the ambulance with Patient #10) revealed the following:
Three patients in-house
R1 68 year old female with Urosepsis - vital signs stable, temp 101.4 degrees Fahrenheit (Tylenol 650mg suppository administered)
R2 74 year old female with COPD (Chronic Obstructive Pulmonary Disease) Chest pain and Hypertension - vital signs stable and patient asleep
R3 89 year old female with pneumonia stable in a swing bed for continued care
Emergency Department
Room 1 - PEC (Patient #1) vital signs stable, family member in attendance
Room 2 - EMPTY
Room 3 - EMPTY Patient #2 left AMA at 2220(10:20am) 12 minutes before the arrival of the ambulance
Room 4 - Patient #3 in need of I&D of finger
Room 5 - EMPTY Patient #12 pediatric patient who had a rock removed from nose, discharged at 22:30
Waiting Room - EMPTY according to the ED Log

Review of the Incident Report completed on 05/01/12 by EMS S7 employed by Company " A " reviewed and approved by their Legal Department revealed .... EMS S17 and I (EMS S7) were on scene with a patient who had taken an unknown amount of pills and vodka. EMS S17 was in the back of the unit trying to get an IV, so she asked me to call report for her. While giving report to RN S5 at Hood Memorial Hospital Emergency Department, at which time she advised me that they " already has a PEC and could not take another " at which time I tried to continue to give report when she said that she would let me talk to the doctor, at which time I handed the phone to EMS S17 and began to drive towards Hood. EMS S17 told me a few minutes later to pull over so she could call Unit 226. Several minutes later she told me to keep going towards Hood ED. When we pulled up to the ED, MD S3 walked around the front of our unit and as I opened the door he stepped in front of me and said " What don ' t you f_ _ _ _ _ _ understand? This my f_ _ _ _ _ _ ER, I said I wasn ' t accepting, f _ _ _ off. " And then he flipped me off and walked away. I then keyed up on the portable radio for 226, who my partner (EMS S17 ) advised she was already on the phone with. I walked to the back of the unit and got in with our patient, while my partner (EMS S17) talked with EMS S18 from Unit 226. We then advised dispatch that we would be transporting to hospital " A " .

Review of the Incident Report completed on 05/01/12 by EMS S17 employed by Company " A " reviewed and approved by their Legal Department revealed ....EMS S7 and I were bringing an overdose patient to Hood Memorial. While on scene I had EMS S7 call the ER so I could establish an IV. EMS S7 passed me the phone saying they were trying to divert my patient (Patient #10). I took the phone so I could speak with the ER doctor. The doctor advised me that he already had one PEC patient and couldn ' t accept my patient. I told the doctor my patient (Patient #10) was an overdose patient and was a Status 3 stable patient, the doctor then stated the ER would be overloaded if we came there. I said OK and called 226 and advised 226 of the situation. I called the ER back and spoke with Dawn the RN who advised the same as the doctor, that they couldn ' t take another PEC. Nurse was advised this patient was an overdose who was a Status 3 and we're two minutes away. The nurse stated she was calling her DON (Director of Nursing) and we could just wait in the hall until she decided what to do. As we stopped in the drive I heard a man yelling at my partner (EMS S7) stating " What part of no don ' t you f_ _ _ _ _ _ ? This is my f _ _ _ _ _ _ ER. I am not f _ _ _ _ _ _ accepting. As I slid the side door open, I observed MD S3 storming back into the ER. I notified 226, and diverted to ______ Hospital " B " .

In a face to face interview on 05/24/12 at 1:00pm Security Guard S8 verified he was on duty on 04/30/12 6P shift. Further S8 indicated during his shift he was called by RN S5 asking for assistance with MD S3. S8 indicated he went immediately to the ED and saw MD S3 speaking with EMS, but he (S8) could not hear what had been said. By the time he reached the door MD S3 was walking back into the ED.

Review of the Emergency Room Record for Patient #10 from Hospital " B " revealed she arrived at the hospital via ambulance on 04/30/12 at 2252 (10:52pm) for a suicide attempt by overdose. Further review revealed vital signs as blood pressure 97/67, respirations 24, oxygen saturation 94% and telemetry indicated normal sinus rhythm. Her eyes opened when name called and her pupils were dilated. Labs were drawn with the following results: Alcohol level High at 159 (<15); positive for Benzodiazepines and cocaine; and Low Potassium 3.1 (3.6-5.2). Patient #10 was given bolus fluids, Zofran for nausea, K-rider, monitored for behavior, and alcohol levels periodically checked. She was PEC ' d at 2300 (11:00pm).

In a face to face interview on 05/22/12 at 7:55am RN S4 Charge Nurse in the Emergency Department on 04/30/12 7P shift indicated she had been employed by the hospital for over thirteen years and had never remembered the hospital ever being on divert. Further S4 indicated the process for diversion was the physician's decision and then he would notify the charge nurse so that the ambulance service could be called. S4 indicated on the night of 04/30/12 she was assigned to triage and the ED was so busy she was not aware of what was going on with Patient #10. S4 indicated the first time she became aware of a problem was when she over heard a telephone conversation between RN S5 and ADON S6 and then saw MD S3 heading out the door toward an ambulance. Further S4 indicated she did not hear what was said between the MD and EMS staff.

In a face to face interview on 05/22/12 at 8:15am RN S5 verified she was on duty the night of 04/30/12. Further S5 indicated the ED was very busy and that the waiting area was full. S5 indicated she took a call from EMS of Company "A" for a patient who had consumed vodka and taken pills. S5 indicated they already had a PEC'd patient and could not take another one because they had no one to sit with the patient and told them they needed to divert. S5 indicated she then called MD S3 to speak to EMS and he told them the same thing. When the ambulance arrived, MD S3 became upset and went out to the ambulance. S5 indicated she called the security guard to go after MD S3 and then called the ADON because she could not locate the charge nurse. RN S5 indicated she could not hear what was being said between the MD and EMS; however she saw the ambulance drive off.

Review of the hospital's policy titled, Diversion of Ambulance Patients, dated approved on 05/20/2003, and provided by the hospital as current policy, revealed the following in part:
Purpose: To identify situations when hospital resources, including emergency services, may occasionally be overwhelmed and diversion of an ambulance may be necessary.
Policy: Ambulance diversions will occur only after the hospital has exhausted all internal mechanisms to avert a diversion. Prior to establishing diversion status, every attempt will be made to maximize bedspace, screen elective admissions, and use all available personnel and facility resources to minimize the length of time on diversion and diversion status will be maintained by the Emergency Department.
Definitions and Indications for Diversion
Emergency Room Divert: 1). At the discretion of the emergency physician, a patient is diverted to another facility due to patient condition requiring the patient to be taken to a closer facility, or based on the medical report, the patient's condition requires a service that cannot be provided at this facility. 2). Emergency department has exhausted resources and staff.


17091