HospitalInspections.org

28650

Based on observation and interview, the facility failed to ensure that patient care supplies stored in the emergency department had not expired. This had the potential to put patients at risk for poor clinical outcomes including infection and inaccurate laboratory test results.

Findings:

On 7/12/12 at 12:23 pm, the supplies stored in the emergency department cabinets and drawers were reviewed with the Infection Control Nurse (ICN), the following items were noted as being expired:

One 16-ounce bottle of 70% rubbing alcohol (a liquid used for disinfecting wounds and/or equipment), with a printed manufacturer's expiration date of 4/2011.

One red top blood collection tube, expired 6/2012.

Two gray top blood collection tubes, expired 5/2012.

During an interview and concurrent observation, on 7/12/12 at 12:40 pm, the ICN confirmed the above findings and stated that the staff should have gone through all the supplies to make sure none had expired.

22705



28650

Based on interview and record review, the facility failed to ensure that medications were administered in a safe and effective manner for 3 of 9 sampled patients (Patients 4, 8, and 9) when:

1a. Patient 8 received Morphine (a narcotic medication) IVP (injected into the vein);

1b. Patient 9 received Demerol (a narcotic medication) IM (injected into a muscle), without written physicians' orders.

2. Medication orders were not written in a clear manner, consistent with standards of practice for Patient 4.

These failures had the potential to put patients at risk for poor clinical outcomes due to receiving medication not ordered for them and not fully understanding their medication/treatment instructions.

Findings:

1. On 7/13/12 at 1:30 pm, during a concurrent interview and record review, the medical records of Patients 8 and 9 were reviewed with Registered Nurse (RN) G.

a. RN G confirmed that Patient 8 had a one-time documented physician's order for Morphine 2 mg (milligrams) IVP (to be pushed directly into the vein). RN G confirmed that according to emergency care flowsheet, Patient 8 received two doses of this medication on 6/1/12 at 10 am and at 10:45 am. RN G stated that their was no documented order for the second dose of Morphine that was given, but that it was most likely a verbal order that had not been documented.

b. RN G confirmed that according to her documentation on Patient 9's emergency care flowsheet, this patient received Demerol 100 mg IM on 6/5/12 at 10:37 am. She confirmed that there was no physician's order documented for this medication. RN G recalled that she had obtained a verbal order for this medication and had not documented it. RN G confirmed that the emergency care flowsheet is not considered an extension of the physician's orders, it is for nursing documentation only. RN G acknowledged that since she had not documented the physician's order at that time, basically it would appear now that she had given the Demerol without an order.

2. On 7/13/12 at 1:30 pm, during a concurrent interview and record review, the medical record of Patient 4 was reviewed with RN G. RN G confirmed that this patient had an order written by Physician C that read, "T # 3 to take home (not here-driving) -1- Q 4-hours PRN. (as needed)" RN G acknowledged that this order was poorly written because "T #3" was never clarified in the patient's instructions as being Tylenol #3 (a type of narcotic pain medication), the PRN portion of the order lacked an indication for why the patient is taking this medication as needed, and the dosage was not clear.

Based on interview and record review, the facility failed to ensure the implementation of its Emergency Records policy and procedure by failing to ensure accurate and complete emergency department (ED) records for 8 of 9 sampled patients when:

1. The dispositions (where the patient went) upon discharge from the ED were not documented for 2 of 9 sampled patients (Patients 2 and 9).

2. Patients conditions upon discharge were not documented for 7 of 9 sampled patients (Patients 1, 2, 3, 5, 7, 8, and 9);

3. Physicians signatures did not include dates and times of signature for 5 of 9 patient records (Patients 1, 5, 6, 8, and 9);

4. EMTALA (Emergency Medical Treatment and Active Labor Act) physician documentation was not completed, as directed in the facility's "Physician's Certification of Medically Indicated Transfer & Patient Consent to Transfer, Form A" and "Patient Transfer Order, Form B" for 3 of 9 sampled patients (Patients 3, 8, and 9).

Incomplete and inaccurate clinical records can put patients at risk for poor clinical outcomes.

Findings:

On 7/13/12 at 1:30 pm, during a concurrent interview and record review, the medical records of Patients 1, 3, 4, 5, 6, 7, 8, and 9 were reviewed with Registered Nurse (RN) G. RN G confirmed the following findings:

1. There was no documentation of disposition following discharge from the ED for Patients 2 and 9.

A review of the facility's undated Emergency Records policy and procedure, indicated, "The purpose of the Emergency Room Records is to document patient treatments in the Emergency Room... Complete Disposition section at the bottom... Mark Time out on the bottom of ER chart..."

2. There was no documentation of patients conditions following discharge from the ED for Patients 1, 2, 3, 5, 7, 8 and 9.

3. Physicians A and B did not validate their signatures with the date and time for Patient records 1, 5, 6 and 8.

4. EMTALA (Emergency Medical Treatment and Active Labor Act) documentation was inaccurate and/or incomplete for Patients 3, 8 and 9.

a. The facility's form titled, "Physician's Certification of Medically Indicated Transfer & Patient Consent to Transfer, Form A" to be completed by the attending physician/medical provider. Physician B did not include the time associated with their signature on this form for Patients 8 and 9.

b. The facility's form titled, "Patient Transfer Order, Form B" instructed the attending physician/medical provider to select only one reason for a patient transfer; A. Unstable Patient or B. Stable Patient. The instructions clearly stated, "Complete Section A or B, but Not Both. However, Physician B had completed both Section A and Section B for Patients 3, 8 and 9. Physician B did not include the time with their signature on this form for Patients 8 and 9.