HospitalInspections.org

43881

Based on surveyor observation, record review, and staff interviews it has been determined that the hospital failed adhere to acceptable standards of Practice to meet the needs of patients in the Emergency Department.

Findings are as follows:

1. The hospital failed to follow their policies and procedures when transferring behavioral health patients from the Emergency Department to other healthcare facilities (Refer to 1104).

2. The hospital failed to follow their wound assessment policy and thoroughly document and describe an open stab wound on a patient assessed by the Physician Assistant in the Emergency Department (Refer to 1104).

3. The hospital failed to ensure daily logs are completed per the hospitals policy, related to emergency equipment, specifically the code carts, observed in the Emergency Department (Refer to 1104).

43881


Based on surveyor observation, record review, and staff interview it has been determined that the hospital failed to follow policies and procedures relative to transferring behavioral health patients from the Emergency Department to other healthcare facilities for 5 of 5 patients reviewed, Patient ID #s 1, 7, 10, 13, and 21. Failed to document the complete wound assessment for 1 of 1 patient reviewed related to a neck laceration, Patient ID #1. Failed to complete the daily code cart checklists for to 3 of 3 code carts observed in the Emergency Department.

Findings are as follows:

1. The hospital's policy titled, "Psychiatric/Behavioral Health Care in the Emergency Department" revised 6/2022 states in part,

" ...Transfer to an Inpatient Psychiatric Treatment Facility:

Upon transfer, a copy of the medical record and all test results, committal papers, interagency transfer sheet, and completed Transfer Certification (EMTALA form) will accompany the patient.

A provider to provider report will be completed and documented in the EMR [Electronic Medical Record]..."

1a. Record review for Patient ID #1 revealed she/he presented to the Emergency Department in April of 2023 via Emergency Medical Service (EMS) who were called by the police who were conducting a wellness check. The patient was brought to the Emergency Department for a behavioral health evaluation. The patient was noted with a wound on the neck. A behavioral health evaluation was performed which determined a diagnosis of suicidal ideation resulting in an emergency certification for psychiatric treatment. The patient was transferred to another hospital the following day.

Patient ID #1's medical record failed to reveal evidence that an interagency transfer sheet or the Rhode Island (RI) Continuity of Care Form was completed and sent with the patient per hospital policy and state regulations. Additionally, the record failed to reveal evidence that a provider to provider report was documented in the patient's medical record per hospital policy.

During a surveyor interview on 4/18/2023 with the Risk Manager she was unable to provide evidence that Patient ID #1 was sent to the receiving hospital with an interagency transfer sheet or Continuity of Care form per hospital policy or that a provider to provider report was documented in the medical record.

1b. Patient ID #7 presented to the hospital in November of 2022 after a Tylenol overdose. The patient received a diagnosis of drug overdose and depression and was transferred to another hospital for mental health treatment.

Patient ID #7's record failed to reveal evidence that an interagency transfer sheet or the RI Continuity of Care Form was completed and sent with the patient upon transfer per hospital policy.

1c. Patient ID #10 presented to the hospital in December of 2022 due to erratic behavior. The patient received a diagnosis of mood disorder and was transferred to another hospital for mental health treatment.

Patient ID #10's record failed to reveal evidence that an interagency transfer sheet or the RI Continuity of Care Form was completed and sent with the patient upon transfer per hospital policy. Additionally, the record failed to reveal evidence that a provider to provider report was documented in the patient's medical record.

1d. Patient ID #13 presented to the hospital in March of 2023 for an overdose. The patient was cleared medically and transferred to another hospital for mental health treatment.

Patient ID #13's record failed to reveal evidence that an interagency transfer sheet or the RI Continuity of Care Form was completed and sent with the patient upon transfer per hospital policy. Additionally, the record failed to reveal evidence that a provider to provider report was documented in the patient's medical record.

1e. Patient ID #21 presented to the hospital in April of 2023 due to alcohol intoxication. The patient was cleared medically and transferred to an inpatient substance abuse facility for treatment.

Patient ID #21's record failed to reveal evidence that an interagency transfer sheet or the RI Continuity of Care Form was completed and sent with the patient upon transfer.

During a surveyor interview on 4/19/2023 at 3:30 PM with the Manager of Case Management, she informed the surveyors that the hospital does not complete a RI Continuity of Care Form when a patient is transferred from hospital to hospital.

2. The hospital's policy titled, "Wound Assessment" dated 2/20/2023, which refers to the Lippincott Manual states in part,

"A thorough wound assessment should consist of objective criteria and measurements that promote accurate, consistent comparisons to determine the extent of the wound and the effectiveness of wound healing ...

" ... Documentation

Documentation associated with wound assessment includes:
...location, size, and appearance of the wound site
... color, type, amount, and order of any drainage
date and time of the assessment ..."

" ... Determine the wound's depth by placing a sterile cotton tipped applicator into the deepest portion of the wound and then comparing the depth to the wound measuring device ..."

A complaint submitted to the Rhode Island Department of Health alleged that an incomplete report was provided to the physician at the receiving hospital, relative to the neck wound on Patient ID #1 who was transferred for psychiatric care. Additionally, the receiving hospital alleges that the patient's record did not clearly document how the wound was evaluated, why it remained open, or the treatment provided to it.

Record review for Patient ID #1 revealed a "Physical Exam" performed upon presentation revealed that Patient ID #1 had a laceration to the left side of the neck measuring 2 centimeters with ecchymosis surrounding the area. The record failed to reveal evidence of a complete wound assessment completed by the physician.

Patient ID #1's record revealed the following initial nursing assessment on 4/4/2023 under a section titled, "General Skin condition" documented the patient's skin a warm, dry, elastic, smooth, and normal. This assessment failed to reveal evidence of bruising or an open stab wound to the patient's neck.

Per hospital policy, Patient ID #1's record did not reveal evidence of the depth of the wound, any treatment provided to the wound nor documentation that treatment was not advised at the time. Additionally, there is no evidence in the patient's record of the color, type, amount, or odor of any drainage present.

During a surveyor interview on 4/18/2023 at 12:06 PM with the Chief Medical Officer, he indicated that it is his expectation that a full assessment is completed, and a plan implemented for each complaint that a patient presents with. He indicated that if the laceration did not require treatment, this should be documented. He acknowledged that there was lack of documentation related to the neck wound.

During a surveyor interview on 4/20/2023 at 12:35 PM with the Risk Manager, she was unable to provide evidence that that wound assessments were completed per hospital policy.

3. Review of the hospital policy titled," Code Blue Carts" last reviewed 9/2017 states in part,

" ...Procedure ...Once each day, during days of operation carts should be checked to ensure lock is intact ...

...Documentation ...Daily, days of operation on the Code Cart Checklist ..."

On 4/19/2023 at 11:50 AM, the surveyor observed three code carts on the unit. Review of the daily Code Cart Checklist for each of the carts revealed the following information:

Code Cart #1 was located in front of the main desk across from room 8, the cart did not contain a daily code cart documentation checklist. Employee A and B were unable to locate a documentation checklist or the clipboard that contained the daily checklist.

Code Cart #2, located in room 10, contained a daily checklist which indicated that the code cart was checked only on the following dates:
4/11/2023
4/16/2023
4/17/2023

Code Cart #3, located in area C, contained a daily checklist which indicated that the code cart was only checked on the following dates:
4/11/2023
4/12/2023
4/16/2023
4/19/2023

During a surveyor interview with Employee A on 4/19/2023 at 11:50 AM, she was unable to provide documentation that daily code cart checks were completed on any other dates other than the dates mentioned above.

During a surveyor interview with the Nursing Director of the Emergency Room on 4/19/2023 at 1:35 PM he was unable to produce evidence that the daily code cart checks had been completed.














45769