HospitalInspections.org

Based on document review, medical record (MR) review and interview, in 1 of 13 (Patient # 2) MRs reviewed, an adolescent patient remained in the ED for 2 days pending psychiatric placement without a daily psychiatric consult. This lack of evaluation could lead to an undetected change in the patient's condition.

Findings include:

-- Review of the hospital's policy and procedure (P&P) titled "Surge Capacity for ED Psychiatric Patients," last revised 3/2010, indicated pediatric psychiatric patients remaining in the ED longer than 24 hours pending placement will be evaluated by psychiatry on a daily basis and the evaluation will be documented in the patient's ED record.

-- Per MR review, Patient #2, presented to the ED on 5/15/17 for a mental health evaluation. An initial psychiatric consult was done on 5/16/17 recommending inpatient psychiatric hospitalization for further stabilization and evaluation at an adolescent child facility. Patient #2 remained in the ED pending placement and was transferred on 5/18/17. There were no psychiatric notes after the initial assessment or at the time of transfer.

-- During interview of Staff G (Quality Improvement Practitioner) on 12/12/17 at 11:45 am, he/she acknowledged the above findings.

Based on observation and interview, Staff H [emergency department (ED) registered nurse (RN)], withdrew injectable medication from a carpuject prefilled syringe cartridge into another syringe prior to medication administration. The Institute for Safe Medication Practices (ISMP), dated 8/2012, indicated this practice of transferring medications from a prefilled carpuject into another syringe increases the risk of medication errors, contamination, staff needlestick injuries.

Findings include:

-- Per observation of Staff H on 12/11/17 at 10:35 am, he/she withdrew Morphine 2 mg (milligrams) from a prefilled carpuject syringe into a separate syringe prior to medication administration.

-- During interview of Staff I (Director of Pharmacy) on 12/11/17 at 1:35 pm, carpujects are not used often, adaptors are available to staff. He/she does not recommend transferring medication from one syringe to another syringe, the carpuject is not meant to be used as a vial to withdraw medication. Staff I acknowledged the above findings at the time of interview.