HospitalInspections.org

Based on MR review, review of P&P and interview with staff, in 3 of 5 ED MR (1, 2 and 4) the facility failed to ensure notations of triage and physical assessment by an RN, documentation of IV start and location, and Pt response to treatment per P&Ps. This deficiency potentially affects all patients treated at the facility during survey.

Findings include:

Per review on 11/19/12 at 11:00 AM of facility policy titled Emergency Department Record and Logging, dated 7/12, it states under Procedure 1.e. "History of injury or illness, vital signs, initial and ongoing assessment utilizing nurse's notes."

Per review on 11/19/12 at 11:15 AM of facility policy titled Procedure of Treatment, dated 7/12, it states under Policy "...Re-evaluation of patient will be done after treatment or medication administration or change in condition..."

Pt #1's MR reviewed on 11/19/12 at 10:00 AM revealed Pt #1 arrived in the ED on 11/17/12 at 2:27 PM, with a complaint of a headache. There is no triage or RN assessment note related to Pt #1's complaint or assessment other than pain and vital signs. An IV of normal saline was ordered during Pt #1's stay, there is a start time of 2:45 PM and stop time of 3:14 PM with no documentation of attempts, location and how fast the IV was running. This is confirmed in interview with MR Rep B on 11/19/12 at 10:00 AM.

Pt #2's MR reviewed on 11/19/12 at 10:10 AM revealed Pt #2 arrived in the ED on 11/15/12 at 3:48 PM, with a complaint of a laceration, and was discharged at 6:46 PM. There is no triage or RN assessment note related to Pt #2's complaint or assessment other than pain, vital signs, and cleansing a wound. Pt #2 was given a dose of Oxycodone (narcotic), one tablet at 6:30 PM, for a pain rating of 5 out of 10 with no documented follow up to ensure effectiveness and any adverse reactions. This is confirmed in interview with MR Rep B on 11/19/12 at 10:10 AM.

Pt #4's MR reviewed on 11/19/12 at 10:30 AM revealed Pt #4 arrived in the ED on 11/13/12 at 7:38 PM, with a complaint of abdominal pain. There is no triage or RN assessment note related to Pt #4's complaint or assessment other than pain and vital signs. An IV of normal saline was ordered during Pt #4's stay, there is a start time of 8:15 PM and stop time of 10:29 PM with no documentation of attempts, location and how fast the IV was running. This is confirmed in interview with MR Rep B on 11/19/12 at 10:30 AM.