HospitalInspections.org

Based on document review and interviews the facility staff failed to ensure the information provided to the patient was a part of the medical record for 3 or 22 patients, Patient #16, 21 and 22. Patients 16, 21 and 22's medical record documented they each received an x-ray (including ultrasounds) and or EKG which was read on the spot by the Emergency Department (ED) physician and if the interpretation changed the patient would be contacted.

The Findings Include:

On 6/12 and 13/12 the medical records of Patient #16, 21 and 22 were reviewed with the Administrative Director of Clinical Operations (ADCO) and the ED manager. HIM (Health Information Management) printed out the complete record for all 3 patients. Patient #16, 21 and 22's medical record each contained the following statement, "The emergency physician provided an on-the-spot interpretation of your x-rays and/ or EKG. A specialist will do a final interpretation of these tests. If a change in your diagnosis or treatment is needed, we will contact you. It is critical that we have a current phone number for you."

The ED manager printed out the information that was provided to Patient #16 at discharge. The above statement was not included in the information printed out by the ED manager. A comparison was made of the information printed by HIM for Patients 21 and 22 again the information in the medical record was not present. There was no way to ensure Patients #16, 21 and 22 had this statement on the information provided to them.

An interview with the local support person for the HIM department with Connect Care (electronic medical record) was completed on 6/13/12 at 3:30 P.M. The support person stated, "That statement is a snap shot in time, when the information is reprinted it drops off. The ADCO stated, "That is a problem. We need to be able to reproduce what is provided to the patient."

Based on observations and interviews the facility staff failed to maintain an effective infection control program in the Emergency Department (ED) as evidenced by torn mattress on gurney in room 12, dirty keyboards and a staff member reaching into a box of supplies for drawing blood and starting intravenous (IV) fluids with bloody gloves.

The Findings Include:

On 6/12/12 during the initial tour of the ED with the ED manager and Administrative Director of Clinical Operations room 12 was observed. The mattress on the gurney in room 12 had a tear in the center of the mattress exposing a porous surface. The porous surface does not allow for cleaning between patient use. The ED manager stated, "I don't know why that is here. That gurney doesn't even belong to the ED. I have numbered all my gurney."

During the tour fixed keyboards were observed in the patient care areas. The keyboards had debris and dirt on them and around the cabinet surface they were secured to. The ED manager stated, "I will get that taken care of immediately."

On 6/12/12 at approximately 1:05 P.M. an observation was made of Employee #5 inserting an IV needle into Patient #2's left arm. Employee #5 was observed reaching into an "IV box" (box filled with tape, needles, blood collection tubes etc.) with blood on the gloves Employee #5 was wearing. The observation was discussed with the ED manager who stated, "I'm glad you seen that, I want to get rid of those boxes and now I have a reason."