HospitalInspections.org

Based on staff interviews and record review the facility failed to insure that the medical record for patient # 3 was complete and accurate.

Based on record review patient # 3 presented to the facility emergency department on 10/16/13 with a primary complaint of sudden onset left sided chest pain. The registered nurse providing care to the patient initiated the emergency room chest pain protocol assessment but did not complete the assessment per electronic medical record [EMR] documentation. Per interview with the nurse who did not complete the assessment s/he disclosed that s/he was likely called out of the patient's room while conducting the assessment and upon return continued with the physical assessment but did not get back into the EMR to conclude the documentation. S/he stated that the chest pain protocol was completed but the documentation was not. The registered nurse stated that providing patient care was of primary responsibility and s/he could not imagine not having completed the entire assessment. S/he admitted that a component of the documentation supporting his/her chest pain assessment was missing from the patient record. On 10/29/13 at 10:30 AM the Emergency Department Director confirmed that the documentation in the EMR was not completed in this patient's electronic medical record.

Based on record review and on staff interview the facility failed to insure that the medical records for patients #1 and #2 were properly maintained to provide complete necessary clinical information.

Based on record review patient #1 presented to the emergency department on 10/15/13 with a chief complaint of chest pain. The registered nurse providing care for the patient initiated the emergency department standing orders protocol for chest pain. The chest pain protocol includes allowing the registered nurse to begin using oxygen at specified parameters per RN assessment of the patient condition. The RN started the patient on two liters of oxygen per nasal cannula. Per record review the emergency department physician responsible for authorizing the use of the oxygen via the standing orders did not sign off the order. On October 29, 2013 at 1000 AM the Emergency Department Director confirmed that the physician did not sign off on the orders.

Patient # 2 presented to the emergency department on 9/30/13 with a chief complaint of chest pain. The registered nurse who assessed the patient initiated the chest pain protocol and administered oxygen at two liters via nasal cannula. Per record review the emergency department physician did not sign off on the orders to administer the oxygen. On October 29, 2013 at 1040 AM the Emergency Department Director confirmed that there was not a physician order signature for approving the administration of oxygen.

Per interview with the Emergency Department Director on October 29, 2013 it was disclosed that the standing order protocols utilized by the nursing staff in the emergency department prior to the launching of the electronic medical record used to be consistently co-signed by the physician as a paper record. The ED Director stated that the advent of the electronic medical record has caused some confusion with the staff in regard to obtaining the physician signature when utilizing standing orders. Per interview with an emergency department physician at 11:00 AM on October 29, 2013, it was disclosed that s/he rarely orders oxygen because the standing orders protocol is in place, but that s/he is fully aware of the patient receiving the oxygen by way of direct visualization and communication with the nursing staff.