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NORTHERN LIGHT EASTERN MAINE MEDICAL CENTER
OFF-CAMPUS EMERGENCY POLICIES AND PROCEDURES
Tag No.: A0094
Complaint Investigation #11224
Based on interviews with key personnel and review of documentation on March 3-4 and 7, 2011, it was determined that the Walk in Clinic (WIC) failed to follow the " EMMC WIC and Retail Clinic policy " .
The evidence follows:
1. On February 27, 2011, a patient presented at the WIC with a complaint of vomiting.
2. According to a statement written on February 28, 2011, by the WIC Registration person, the patient presented to the WIC registration, and she called the charge nurse to assess the patient. She documented, " .... (RN) looked at the patient and let the caseworker know that this was not something that walk in care could handle and the patient needed to go to the emergency room. The case worker asked (RN) for directions to the emergency room .... "
3. According to a statement written on March 2, 2011 by the WIC Registered Nurse (RN), she assessed the patient sometime after 5:00 on February 27, 2011. She wrote, " I explained that [he/she] really was a higher level of care since [he/she] clearly could not transfer [himself/herself] or speak. I would recommend that [he/she] go the emergency room. I gave the female [caseworker] directions to the emergency room, and she left ... "
4. The EMMC WIC and Retail Clinic policy III B. states " if after nursing or medical assessment a decision is made that a patient would be more safely treated in another care site: ...2. The provider will notify and have direct provider- provider conversation with clinician at proposed site of transfer. 3. The provider will assess the best mode of transport given the patients clinical status. 4. The provider will send relevant clinical information, including vital signs, history with examination ... ...These elements will be clearly documented on transfer form that will accompany the patient."
5. There was no documentation to indicate that this policy was followed by the WIC staff in the disposition of this patient.
6. The content of this policy and the actions WIC Staff were confirmed in an interview with the Director, Accreditation and Regulatory Standards on March 7, 2011.