HospitalInspections.org

Based on interview and record review the facility failed to ensure the accuracy of the medical record for one (#1) of 9 records reviewed for accuracy out of a total of 16 sampled patients, resulting in the potential for less than optimal outcomes for patient #1. Findings include:

Review of patient #1's medical record revealed the following on 7/19/2021 at 1100. The patient (#1) was a 43-year-old-female that presented to the facility's Emergency Department (ED) on 3/15/2021 at 1646. The patient was discharged on 3/15/2021 at 2156 per physicians' orders.

Review of ED triage notes dated 3/15/2021 at 1711 documented the patient (#1) presented to the ED with the chief complaint of generalized body pain. The patient's pain score was recorded as a "9" on a scale of 1-10 with "10" being the worse pain. The patient's triage Emergency Severity Index (ESI) was a level "3", (lower risk).

Review of Medical Doctor (Staff D) "ED General Treatment Note", dated 3/15/2021 at 1754 documented the following:
Chief Complaint: My back hurts
History of Present Illness: "This patient comes to the emergency department with emerged part with acute exacerbation of chronic back pain ...is 8 currently 8 or 10 is achy pain is relived with her home medications. Patient reports she has a prescription but unable to get up. Patient reports no other complaints states she otherwise feels fine."

Medical Decision Making and Course in the ED:
This is a pleasant 43-year-old female coming to the ED with acute exacerbation of chronic pain.
Patient has back pain.
Normal neurological exam
No history of IV drug abuse. This point in time will give the patient a dose of pain medication she had relief and we discharged her home.

Final Impression(s) Diagnoses:
Acute back pain

Disposition: The patient is discharged home in stable condition. I have asked the patient to return for any further problems. The patient is to return to the ED for worsening signs or symptoms, otherwise follow up with her PCP within one week.

Review of nursing progress notes documented the following:
On 3/15/2021 at 2159, "patient asked multiple time to get off her phone and recording staff, security called and asked to assist with the patient's discharge, patient being verbally aggressive with staff."
On 3/15/2021 at 2200, "patient escorted out with security. Patient asked multiple time to get off her phone and recording staff, security called and asked to assist with the patient's discharge, patient being verbally aggressive with staff."

Review of medication orders and patient medication administration records (MAR's) revealed there were orders for Acetaminophen-Hydrocodone by mouth one time only, dated 3/15/2021 at 2129 and Diazepam 5mg dated 3/15/2021 at 2130 by mouth one time only. However, they were not documented as administered or refused on the MAR's.

A phone interview was conducted with Medical Doctor Staff D on 7/19/2021 at 1135. He explained that he recalled the patient. He said he was able to review his notes. Staff D stated, "after reviewing my notes I probably should have documented that the patient was discharged against medical advice (AMA)." When asked to explain why, he replied, she (#1) was belligerent, she was recording people. He further explained his resident ordered lab work, but it (panels, pregnancy tests, urinalysis, and urinary drug screen) was not necessary. He said, she endorsed using and it does not change anything we will still treat patients. When asked to clarify if her pain was addressed and if she received the prescribed pain medication, he said he thought it was done.

Staff D was further queried regarding the accuracy of the patient's chart namely her (#1) receiving pain medication with relief, and her disposition home in a stable condition. At that time, Staff D replied, I should have documented better. Staff D said, I was planning on discharging her. He said, I did not have a plan to go over AMA with her. He said, if I could have had a little more time to do over things in retrospect, I would have.