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Based on record review and interview the facility failed to protect the personal privacy of 1 of 20 patients whose records were reviewed from January 2019 through October 2019, 10 months. (Patient's #1 through #20)


This deficient practice had the likelihood to effect all patients of the facility.


On 10/29/2019 a written complaint, received from patient #2 (Pt/pt) indicated she had been treated in the hospital Emergency Department on 6/27/2019 at 10:03 AM and was discharged on 6/27/2019 at 1:46 PM. After discharge she reviewed her discharge information to find information for patient #19 in her discharge papers.

A review of the compliant log for the facility did not reflect a complaint from Pt #2, however, interview revealed she knew pt #19's first middle and last name and date of birth. The information was described as educational in description.

A medical records review of both patient #2 and patient #19 indicated both patients were treated in the Emergency Department on the same night. Further review revealed, pt.#2 was discharged from the Emergency Department in stable condition while patient #19 was admitted for inpatient services. Review of their medical records indicated both patients were treated appropriately.

Interview with ED Director found no knowledge of medical records from any patient being placed in the wrong discharge folder. The ED Director also confirmed she could not deny that it occurred.

The medical records for 19 other patients did not reflect misfiled or other medical records components that were at risk of privacy violations.

The facility failed to insure the personal privacy of protected health information for pt #19.

Based on observation, interview, and record review the facility failed to provide care in a safe setting by not ensuring that Intravenous fluids were administered in a timely manner to 1 (#3) out of 20 patients reviewed.

The deficient practice had the likelihood to cause harm and potentially death to a patient in the emergency room.

The findings are as follows:

Review of the patient's medical record revealed the patient, approximately 5 months old, was brought to the Emergency Room on 09/20/2019 at 3:26 p.m. The patient was triaged by a nurse at 3:27 p.m. with a chief complaint documented as: "Patient here for fever, has a metabolic disorder and is going to be transferred to The Speciality Hospital, is on Tamiflu for flu exposure." Further review of the medical record revealed the patient had a rectal temperature of 101.3 degrees Fahrenheit. The patient was then seen by another nurse at 4:11 p.m. and by a nurse practitioner at 4:14 p.m. The patient was ordered Acetaminophen 112 mg oral liquid, Complete Blood Count, Comprehensive Metabolic Panel, Influenza A Antigen, Influenza B Antigen, RSV Antigen, Streptococcus A screen/and culture as well as a peripheral IV (intravenous line) to be inserted.

Documentation revealed a third nurse spoke with a physician, who is familiar with the patient at a specialty hospital where the patient receives treatment for a rare metabolic disorder, about recommendations on treating the patient until he could be transferred. Per the documentation the physician confirmed the patient was at risk for metabolic stroke and the patient needed to be started on D10 (Dextrose 10%) ½ NS (0.45% Normal Saline) at 50 milliliters per hour IV as soon as possible, to initiate transfer to The Specialty Hospital and to not wait on lab results to start IV fluids.
Further review of the documentation revealed the Emergency Room physician order for the IV fluid D10 ½ NS was entered at 5:40 p.m. The documentation revealed an order to initiate transfer to The Speciality Hospital was entered at 5:48 p.m., the patient was accepted at 6:01 p.m. and transferred out at 7:22 p.m. Documentation revealed the IV fluids were received in the emergency room at 6:35 p.m. and not administered until 6:40 p.m.

Review of the facility's grievance investigation provided by the facility revealed the patient's grandmother provided a letter from the patient's physician at The Specialty Hospital. This document gives very specific details of how to treat the patient and gives phone numbers of the physicians and on-call service to call should this patient arrive at an emergency room other than The Specialty Hospital. The facility investigation revealed the nurse and nurse practitioner saw the document and returned it to the grandmother, no copy was placed in the patient's medical record. The investigation also revealed the emergency room physician reported never seeing the document.

Review of documents from the U.S. National Library of Medicine identifies the patient's medical condition as; "an inherited disorder in which the body is unable to process certain proteins properly. It is classified as an organic acid disorder, which is a condition that leads to an abnormal buildup of particular acids known as organic acids. Abnormal levels of organic acids in the blood (organic acidemia), urine (organic aciduria), and tissues can be toxic and can cause serious health problems ... ...Stress caused by infection, fever or other demands on the body may lead to worsening of the signs and symptoms, with only partial recovery ... .....It has been shown that in the majority of neonatally diagnosed patients striatal injury can be prevented by combined metabolic treatment ... ... ... intensified emergency treatment during acute episodes of intercurrent illness should be introduced and monitored by an experienced interdisciplinary team. However, initiation of treatment after the onset of symptoms is generally not effective in preventing permanent damage."

An interview with the CNO, Quality Director and ER director on 10/30/2019 at approximately 9:00 a.m. revealed the patient advocate that handled this grievance no longer works for the facility. When asked why it took over an hour for the patient to receive the IV fluids, the ER director stated, "on that day, the emergency room was overwhelmed with patients due to the tropical storm, another patient in critical condition arrived in the emergency room shortly after this patient was seen and the staff were attending to them."