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Based on medical record review and document review, in one (1) of 14 medical records, Nursing Staff did not implement nursing policy and procedure for the assessment of pediatric patient to ensure the development of a care plan that meets the care needs of the patient (Patient #1).

Findings include:

Review of medical record for Patient #1 identified that this pediatric patient presented at the facility Emergency Department (ED) on 6/24/16 at 2314 with a temperature of 102.6 Fahrenheit (F)(Normal range is 97F to 98.9F) The patient also presented a second time at the ED on 6/25/16 at 1557 with a temperature of 104 F. The patient's mother reported body rash and patient's inability to tolerate prescribed doses of oral medications.

Nursing assessments of the patient during the first visit on 6/24/16 and the second visit on 6/25/16 were not conducted in accordance with the facility's policy and procedure titled: "Nursing Assessment of the Pediatric Patient in ED". The policy required the following assessments to be conducted on all pediatric patients: 1) skin color and capillary refill time; 2) movement of extremities; 3) comparison of the extremities bilaterally for swelling, movement, deformities, sensation, strength, pulses bruises and rashes.

As a result of the lack of detailed assessment, the patient's skin condition was not identified and a care plan developed.

Based on observations, and interview, the facility did not maintain the condition of the Emergency Department environment to ensure the safety of patients.

Findings Include:

A tour of the Emergency Department (ED) on 10/31/16 between 11:45AM and 12:30pm identified the following:

1. 2 packages of lap sponges that expired on 9/20/16 were noted in a in a storage.

2. 4 hand-washing sinks located in the Emergency Department did not have running hot water.

3. The ice dispenser had crusty debris within the dispenser spout.

4. The storage room dedicated for the storage of items left by Emergency Medical Services (EMS) had dirty blankets and other items stored on the floor.

During interview with Staff F, Nurse Manager on 10/31/16 at the time of observations, she acknowledged the findings.

Based on medical record review, document review, and interview, in one (1) of 14 medical records reviewed, the facility did not implement its policies and procedures to ensure that each patient presenting to the Emergency Department receives a comprehensive history and physical examination (Patient #1).


Findings include:

Review of the medical record for Patient #1 identified the following: On 6/24/16 at 2317 (11:17 PM), patient #1, a pediatric patient was seen in the Emergency Department (ED) with a primary complaint of a high temperature of 102.6 Fahrenheit (F) (Normal range 97 F to 98.9 F). The patient was assessed by the physician and the documentation noted that the skin was negative for color change and rash. A diagnosis of Non- Suppurative Otitis Media (Acute ear infection) was made. There was no documentation of a full assessment of the patient as prescribed by the Medical Staff Bylaws.

Patient #1 returned to the ED on 6/25/16 at 1557 (3:57 PM) with a temperature of 104 degree F. Another physician examined Patient #1 and noted; "Abrasion dorsum of R foot over an old abrasion with diffuse erythema and edema extending to the ankle."

The Initial Physician Assessment in the ED on 6/24/16 at 2317 did not identify the changes in the patient's skin condition.


Review of Medical Staff Bylaws, last reviewed on 1/2016, Section A, subtitle "History and Physical Examination" stated the following: " Physical Examination is to include inventory of the body system and vital signs."


During interview with Staff J, Physician on 11/2/16 at 11:15 AM in the presence of Staff A, the Medical Director, he stated the child was very active, there was no suggestion of a limitation in movement, and he did not check for any condition in the patient ' s lower extremities.

As a result of the lack of full assessment that includes the inventory of body systems, the presence of " Abrasion dorsum of R foot over an old abrasion with diffuse erythema and edema extending to the ankle" was missed and was not treated at the time of the first visit.