HospitalInspections.org

Based on review of a facility Procedural Guideline, review of the facility's Emergency Room Log, medical record review, and interview, the facility failed to maintain complete and/or accurate medical records for five patients (#8, #16, #17, #18, #19) of twenty sampled patients.

The findings included:

Review of the facility's Procedural Guideline titled "Pivot Process" dated May 20, 2011, revealed, "...The Pivot Process was developed...in response to the negative impact Emergency Department (ED) overcrowding was having on our ability to care for patient...goals...reduced waiting room time...The Pivot MLP (Mid Level Pracitioner) uses a T 94 sheet to communicate pertinent information to the MD (Medical Doctor) or MLP who continues care...Elopement and AMA (Against Medical Advice) If a patient informs the staff that he or she wishes to leave and forego treatment after the MSE (Medical Screening Exam)...If a patient chooses to leave, a physical exam will be documented...An AMA form will be completed. On occassions, the...patient will leave without informing the staff of their intent. Those patients are considered elopements...Definitions: Left Without Being Seen...patient who leaves the ED without being evaluated by a Qualified Medical Provider (QMP)...Left Without Treatment (LWOT): a patient who leaves the ED after being evaluated by a QMP but before treatment or care is complete. Eloped - a patient who has been seen by a QMP and leaves the ED without notifying staff before treatment or disposition is complete. Against Medical Advice (AMA): Any patient recognized by the hospital as electing to discontinue care by leaving after being evaluated by a Qualified Medical Provider (QMP) but before the Emergency Department encounter is officially ended or care completed...includes documentation...by medical care staff of patient refusal to complete, documentation confirming the intent to leave against the recommendation or advice of the QMP...Identification of persons leaving without being seen, left without treatment, including eloped, or against medical advice will remain on the Emergency Department Log, along with proper documentation of the circumstances of the individual's departure..."


Medical record review of an ER Provider Record for patient #8, dated May 3, 2012, revealed, "chief complaint: chest pain...Clinical Impression Chest Pain...Disposition admitted..." Medical record review of a Release From Responsibility For Discharge form dated May 4, 2012, at 3:40 a.m., and signed by the patient revealed, "...am leaving...against the advice of the attending physician...have been informed of the risk involved..." Medical record review of an ED Nursing Record dated May 4, 2012, at 3:40 a.m., revealed, "...D/C instructions given with AMA."

Interview with a corporate Divisional Vice President on May 16, 2012, at 3:50 p.m., in a conference room, confirmed the facility failed to maintain an accurate medical record for Patient #8.


Medical record review revealed Patient #16 presented to the facility's ED on February 22, 2012. Medical record review of a Transfer of Care form dated February 22, 2012, at 7:05 p.m., revealed, "...Supervision Note 94...c/o B (bilateral) LE (lower extremity) swelling sent by PCP (primary care physician) for evaluation...discussed with Dr.(name deleted) - OK for U/S...(ultrasound)..."

Medical record review of an ED Physician Order Sheet dated February 22, 2012, revealed, "...US (bilateral) LE." Medical record review of a Final Report dated February 22, 2012, revealed, "...US Venous Extremity Bilat (bilateral)...No evidence for left or right femoral or popliteal DVT (Deep Vein Thrombosis) If clinical symptoms persist or progress, consider repeat DVT ultrasound study in 3-5 days..."

Medical record review revealed no documentation on an ER Provider Record, ED Nursing Assessment, ED Nursing Record, and/or documentation regarding the disposition of Patient #16.

Telephone interview with the facility's ED Clincal Leader on May 17, 2012, at 1:53 p.m., revealed the patient's disposition was AMA, and confirmed the facility failed to maintain an accurate medical record for Patient #16.


Medical record review revealed Patient #17 presented to the facility's ED on February 22, 2012. Medical record review of a Transfer of Care form dated February 22, 2012, at 6:28 p.m., revealed, "...Supervision Note 94...reports vomiting...P (Plan): exam (examination) by provider..." Medical record review of an ED Triage Record dated February 22, 2012, at 7:00 p.m., revealed, "Chief complaint...vomited few times today and diarrhea...To lobby @ time: (7:03 p.m)..." Medical record review revealed no documentation regarding the disposition of Patient #17.

Telephone interview with the ED Clinical Leader on May 17, 2012, at 3:25 p.m., confirmed the facility failed to maintain an accurate medical record for Patient #17.


Medical record review revealed Patient #18 presented to the facility's ED on February 22, 2012. Medical record review of a Transfer of Care dated February 22, 2012, at 8:31 p.m., revealed, "...emesis (vomiting)...P (Plan): exam by provider..."

Medical record review revealed no documentation regarding disposition of Patient #18.

Telephone interview with the ED Clinical Leader on May 17, 2012, at 1:50 p.m., confirmed the facility failed to maintain an accurate medical record for Patient #18.


Medical record review revealed Patient #19 presented to the facility's ED on March 28, 2012. Medical record review of an Emergency Provider Record dated March 28, 2012, revealed, "chief complaint: tender swollen R (right) forearm...Clinical Impression Cellulitis...RUE (right upper extremity)...home." Medical record review of a Transition Record Summary dated 3/(illegible), revealed, "...Your Final Diagnosis after being examined and treated by the doctor is: Abscess..."

Telephone interview with the ED Clinical Leader on May 17, 2012, at 1:35 p.m., confirmed the facility failed to maintain an accurate medical record for Patient #19.

Based on review of a facility Procedural Guideline, review of facility policy, review of Emergency Room Logs, medical record review, and interview, the facility failed to accurately document the disposition for four patients ( #15, #16, #17, #18) of twenty sampled patients.

The findings included:

Review of the facility's Procedural Guideline titled "Pivot Process" dated May 20, 2011, revealed, "...The Pivot Process was developed...in response to the negative impact Emergency Department (ED) overcrowding was having on our ability to care for patient...goals...reduced waiting room time...The Pivot MLP (Mid Level Pracitioner) uses a T 94 sheet to communicate pertinent information to the MD (Medical Doctor) or MLP who continues care...Elopement and AMA (Against Medical Advice) If a patient informs the staff that he or she wishes to leave and forego treatment after the MSE (Medical Screening Exam)...If a patient chooses to leave, a physical exam will be documented...An AMA form will be completed. On occassions, the...patient will leave without informing the staff of their intent. Those patients are considered elopements...Definitions: Left Without Being Seen...patient who leaves the ED without being evaluated by a Qualified Medical Provider (QMP)...Left Without Treatment (LWOT): a patient who leaves the ED after being evaluated by a QMP but before treatment or care is complete. Eloped - a patient who has been seen by a QMP and leaves the ED without notifying staff before treatment or disposition is complete. Against Medical Advice (AMA): Any patient recognized by the hospital as electing to discontinue care by leaving after being evaluated by a Qualified Medical Provider (AMP) but before the Emergency Department encounter is officially ended or care completed...includes documentation...by medical care staff of patient refusal to complete, documentation confirming the intent to leave against the recommendation or advice of the QMP...Identification of persons leaving without being seen, left without treatment, including eloped, or against medical advice will remain on the Emergency Department Log, along with proper documentation of the circumstances of the individual's departure..."

Review of facility policy titled "Emergency Medical Treatment and Labor Act (EMTALA) dated July 14, 2011, revealed, "...The hospital will keep a central log indicating each individual who came to the emergency department seeking care and whether the patient refused treatment, was treated and admitted, was transferred, or was discharged..."

Review of the facility's ER (Emergency Room) Log dated February 19, 2012, revealed Patient #15 left without being seen.

Medical record review revealed Patient #15 presented to the facility's ED on February 19, 2012. Medical record review of an Emergency Provider Record dated February 19, 2012, revealed, "...chief complaint: sexual assault...tx (treatment) per SANE (Sexual Assault Nurse Examiner)...Also Rx (prescription) given...Disposition Decision Time 9:42 (a.m.) Disposition home ..."

Interview with the ED Clinical Leader on May 16, 2012, at 2:00 p.m., in a conference room, confirmed the facility failed to accurately document the disposition of Patient #15 on February 15, 2012.


Medical record review of the facility's ER Log dated February 22, 2012, revealed sampled Patient #16 left without being seen.

Medical record review revealed Patient #16 presented to the facility's ED on February 22, 2012. Medical record review of a Transfer of Care form dated February 22, 2012, at 7:05 p.m., revealed, "...Supervision Note 94...c/o B (bilateral) LE (lower extremity) swelling sent by PCP (primary care physician) for evaluation...discussed with Dr.(name deleted) - OK for U/S...(ultrasound)..."

Medical record review of an ED Physician Order Sheet dated February 22, 2012, revealed, "...US (bilateral) LE." Medical record review of a Final Report dated February 22, 2012, revealed, "...US Venous Extremity Bilat (bilateral)...No evidence for left or right femoral or popliteal DVT (Deep Vein Thrombosis) If clinical symptoms persist or progress, consider repeat DVT ultrasound study in 3-5 days..."

Medical record review revealed no documentation regarding disposition of Patient #16.

Telephone interview with the facility's ED Clincal Leader on May 17, 2012, at 1:53 p.m., revealed the patient's disposition was AMA and confirmed the facility failed to accurately document the disposition of Patient #16 on the facility's ER Log on February 22, 2012.


Review of the facility's ER Log dated February 22, 2012, revealed sampled Patient #17 left before triage.

Medical record review revealed Patient #17 presented to the facility's ED on February 22, 2012. Medical record review of a Transfer of Care form dated February 22, 2012, at 6:28 p.m., revealed, "...Supervision Note 94...reports vomiting...P (Plan): exam (examination) by provider..." Medical record review of an ED Triage Record dated February 22, 2012, at 7:00 p.m., revealed, "Chief complaint...vomited few times today and diarrhea...To lobby @ time: (7:03 p.m)..."

Medical record review revealed no documentation regarding the disposition of Patient #17.

Telephone interview with the ED Clinical Leader on May 17, 2012, at 3:25 p.m., confirmed the facility failed to accurately document the disposition of Patient #17 on the facility's ER Log on February 22, 2012.


Review of the facility's ER Log dated February 22, 2012, revealed Patient #18 left without being seen.

Medical record review revealed Patient #18 presented to the facility's ED on February 22, 2012. Medical record review of a Transfer of Care dated February 22, 2012, at 8:31 p.m., revealed, "...emesis (vomiting)...P (Plan): exam by provider..."

Medical record review revealed no documentation regarding disposition of Patient #18.

Telephone interview with the ED Clinical Leader on May 17, 2012, at 1:50 p.m., confirmed the facility failed to accurately document the disposition of Patient #18 on the ER Log dated February 22, 2012.