HospitalInspections.org

Based on record review and interview the Emergency Department staff failed to follow their policy and procedures by failing to document their required admission screenings in 2 of 10 medical records reviewed (Patient #1 and Patient #6) in a total of 10 emergency medical records reviewed.

Findings include:

Review of policy titled "Care of the Patient Requiring Emergency Care" #6415321, dated 6/2019, under procedure revealed "The emergency RN [registered nurse] collects comprehensive data pertinent to the health care consumer's health and/or situation."

Review of policy titled "Interdisciplinary Documentation" #4347889, dated 8/2020, last revised 9/2017, revealed "Acute care needs are determined through a comprehensive assessment and screening. Data is collected in a collaborative manner to avoid duplication and is documented and retrievable by all disciplines."

Review of the "Stroke Alert Flow" dated 12/13/18, revealed "RRT [rapid response team] RN & Staff RN Collaborate to Complete: NIHSS [National Institutes of Health Stroke Scale] (if not already done)."

On 10/07/20 at 2:45 PM during interview with Emergency Department Supervisor (EDS) D, EDS D stated every time a patient presents to the Emergency Department, it is the expectation that the following screening assessments are completed in the electronic medical record by the primary registered nurse (RN): advanced directives, abuse indicators, depression/suicide screening, fall risk, travel screen, infectious disease, sepsis, and BEFAST (American Heart Association indicators of stroke) and a Glascow screening (indicates level of responsiveness) on admission and discharge.

Review of Patient #1's medical record revealed Patient #1 presented to the Emergency Department on 3/10/2020 with a chief complaint of "abnormal Lab" (laboratory), CT (computerized tomography/x-ray) of the chest was done to rule out pulmonary embolism (PE) (negative for PE), and was discharged home 3/10/2020. There was no BEFAST screen (American Heart Association indicator for stroke) or NIHSS screen (National Institutes of Health Stroke Scale) documented. There was no Glascow screen on discharge.

Review of Patient #6's medical record revealed Patient #6 presented to the Emergency Department on 3/12/30 at 9:58 PM with a chief complaint of altered mental status and was discharged home 3/13/20 at 12:35 AM. There was no BEFAST or fall screening documented. There was no Glascow screen documented on discharge.

On 10/08/20 at 10:20 AM during interview with Patient Care Supervisor of the Emergency Department D, EDS D confirmed there was no BEFAST, NIHSS or Glascow screens on discharge documented by the Registered Nurse for Patient #1 and #6.