HospitalInspections.org

Based on medical record review, and staff interview the facility failed to ensure medical records were accurately documented for 2 of 13 patient records reviewed (#1, #2). The findings were:

1. Medical record review for patient #1 showed the patient was admitted on 6/3/22 to the emergency room and was being treated for seizures. Review of the nursing notes dated 6/3/22 and timed 12:50 PM showed the patient requested to use the bathroom. The patient requested privacy and the nurse stepped out of the bathroom. The nurse heard a crash and found the patient lying on the floor actively seizing with blood coming out of his/her nose. Further review of the nursing notes showed the patient required assistance with breathing and received chest compressions due to inability to feel a pulse during the seizure. The ER physician reviewed the following radiology tests: computed tomography (CT) head, CT maxillofacial with communited nasal bone fracture, and CT of the chest. Further review of the medical record showed the discharge clinical impression was seizure, and simple laceration of the nose. The following concerns were identified:
a. Review of the emergency department (ED) Physician Report electronically signed and dated on 6/3/22 at 2:47 PM failed to show documentation of the seizure in the bathroom in which the patient required cardiopulmonary rescusitation.
b. Interview on 9/7/22 at 3:20 PM with the emergency room director confirmed the ED Physician Report did not show documentation of the seizure in the bathroom that resulted in a nasal fracture.
c. Interview on 9/7/22 at 4:30 PM with the medical director stated the physician who saw the patient was new to the facility and had trouble with the dictation system. He confirmed the seizure that resulted in a nasal fracture should have been documented.

2. Review of the medical record for patient #2 showed the patient was seen in the emergency room on 6/3/22 for complaints of chronic cough. Review of the discharge instructions showed the patient received an antibiotic and an oral steroid. The following concerns were identified:
a. Review of the medical record failed to show documentation of the visit from the physician.
b. Interview on 6/3/22 with the emergency room director confirmed the medical record did not have a documentation of the visit from the physician. She further stated the expectation was for the emergency room physicians to document all patient care encounters.