HospitalInspections.org

Based on document review and staff interview, it was determined that the facility failed to ensure that all medical records, included documented reports of treatment, interventions and assessments of the patient's condition.

Findings include:

1. On 4/23/17 at 17:28, Patient #1 was brought to the ED in full Cardiac and Respiratory Arrest, and a code was initiated.

a. Upon review of the medical record, it was determined that the code event was not entered into the Epic Code Recorder in the EMR.

i. The EMR indicated, that Patient #1 was brought in by his/her mother at 17:28, unresponsive, bleeding from the nose and mouth, with no heart sounds, no pulse and not breathing. Doctors were at the patients' bedside, suctioned the patient, and at the same time CPR was started. 17:34 ..."was given Epi 0.064 mg/flushed with NS. At 17:39 was given Atropine 0.13 mg, checked rhythm- noted PEA. Given 2nd dose of Epi at 17:36 0.065 mg/flushed at 17:39. At 17:40 was given 3rd dose of Epi. At 17:45 was given 4th Epi. At 17:46 Bicarb 6.5 #2. Noted heart rate 140'. 100 ml NS in progress. B/P 61/40, heart rate 122', O2 Sat 92%. All code meds was [sic] given IO-left leg by primary RN."

ii. Upon interview Staff #1 stated the EMR system had been in place for seven weeks as of 4/23/17. The code documentation was not completed in the Epic Code Recorder, nor was a paper Code Recorder used (available if the EMR system is not functioning). It was confirmed with Staff #1, the facility does not have a code policy and procedure.

2. The facility failed to ensure that all necessary information during the code was documented in Medical Record #1.

Based on medical record review, review of facility documents and staff interview, it was determined the facility failed to follow its policy and procedures.

Findings include:

Reference: Transfer of Patients to Another Acute Care Facility P&P stated, ..."Procedure... 6. The attending physician/designee will initiate transfer orders on in-house patients... 8. The Emergency Department physician, or in the case of an in-house patient transfer the attending physician or his/her designee, will inform the patient or responsible party of the risks and the benefits of transfer and document them on the Certification and Consent to Transfer form... 9. Before transfer occurs the patient or patient's representative will sign the Certification and Consent to Transfer form..."

1. Review of the medical record dated 4/23/17, indicated the following:

a. The "ED Events" indicated, Patient departed from the ED at 19:17, and the patient was discharged at 20:19.

b. The "ED Disposition" indicated, Transfer to PICU [hospital], and the accepting attending Dr. [name].

c. The "Course/Medical Decision Making" indicated at 18:44, ...Vitals stabilized, called (hospital name) Ped ER, was told to call PICU. Spoke with Resident (name) who after discussing with her attending (name) who accepts patient transfer to PICU. Transporter arrived and transferred safely..."

d. The "Care Timeline" indicated, at 19:17, patient discharged.

2. Upon interview Staff #1 stated the discharge disposition and transfer of Patient #1 was noted in the EMR, however there was no Physician electronic or written orders, for the transfer of Patient #1. The transfer risks and benefits for Patient #1, were not in the EMR, or on a Transfer form.

3. The "Certification and Consent to Transfer" form, was also not part of the EMR.