HospitalInspections.org

Based on interview, one of one medical records in its original form was not made available on the day of survey for a Patient evaluated in the Emergency Department ( ED) in August 2010.

The findings are as follow:

The Patient was evaluated in the ED on 08/16/10 and discharged back to a long-term care facility on 08/17/10 after both a medical screening and a psychiatric evaluation.

Although, a copy of the Patient's ED record was provided to the Surveyor at the time of survey there was insufficient documentation in the copied ED record to make a determination about the application of four point restraints, monitoring of the Patient in restraints and the opportunities; if any for the release of the restraints.

Registered Nurse #1 was interviewed on 08/19/10 at 3:20 PM. Registered Nurse #1 said the Patient was placed in four point restraints. There were no restraint flowsheets found in the copied ED record. There was no documentation for the Patient's response to the restraints.

Registered Nurse #1 said the Patient had been issued a one to one sitter. There was no documentation provided to the Surveyor that the Patient was issued a one to one sitter.

The Hospital failed to ensure that a Patient's medical record was accessible on request on the day of survey. The Patient had been evaluated in the ED two days prior to the survey.