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Tag No.: C2408
Based on review of medical records and staff interview, it was determined the facility failed to ensure a delay in treatment was prevented from occurring in the Emergency Department (ED) in sixteen (16) of twenty five medical (25) records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16). This has the potential to negatively affect all patients presenting to the ED by not receiving emergent care when necessary.
Findings include:
1. Patient #1 presented to the ED on 11/25/11 at 1105. Nursing was not notified of patient's presence until 1109. This represents a four (4) minute delay in notification.
2. Patient #2 presented to the ED on 11/28/11 at 1459. Nursing was not notified of patient's presence until 1619. This represents a one (1) hour and twenty (20) minute delay in notification.
3. Patient #3 presented to the ED on 11/23/11 at 0139. Nursing was not notified of patient's presence until 0227. This represents a fifty eight (58) minute delay in treatment.
4. Patient #4 presented to the ED on 11/18/11 at 1600. Nursing was not notified of patient's presence until 1644. This represents a forty four (44) minute delay in treatment.
5. Patient #5 presented to the ED on 11/22/11 at 2000. Nursing was not notified of patient's presence until 2035. This represents a thirty five (35) minute delay in treatment.
6. Patient #6 presented to the ED on 11/20/11 at 1611. Nursing was not notified of patient's presence until 1642. This represents a thirty one (31) minute delay in treatment.
7. Patient #7 presented tot he ED on 11/21/11 at 1210. Nursing was not notified of the patient's presence until 1240. This represents a thirty (30) minute delay in treatment.
8. Patient #8 presented to the ED on 11/16/11 at 1213. Nursing was not notified of the patient's presence until 1241. This represents a twenty eight (28) minute delay in treatment.
9. Patient #9 presented to the ED on 11/16/11 at 1706. Nursing was not notified of the patient's presence until 1732. This represents a twenty six (26) minute delay in treatment.
10. Patient #10 presented to the ED on 11/20/11 at 1420. Nursing was not notified of the patient's presence until 1442. This represents a twenty two (22) minute delay in treatment.
11. Patient #11 presented to the ED on 11/21/11 at 1459. Nursing was not notified of the patient's presence until 1520. This represents a twenty one (21) minute delay in treatment.
12. Patient #12 presented to the ED on 11/28/11 at 1458. Nursing was not notified of the patient's presence until 1519. This represents a twenty one (21) minute delay in treatment.
13. Patient #13 presented to the ED on 11/27/11 at 0017. Nursing was not notified of the patient's presence until 0033. This represents a sixteen (16) minute delay in treatment.
14. Patient #14 presented to the ED on 11/24/11 at 1905. Nursing was not notified of the patient's presence until 1916. This represents an eleven (11) minute delay in treatment.
15. Patient #15 presented tot he ED on 11/29/11 at 1454. Nursing was not notified of the patient's presence until 1504. This represents a ten (10) minute delay in treatment.
16. Patient #16 presented to the ED on 11/30/11 at 1218. Nursing was not notified of the patient's presence until 1228. This represents a ten (10) minute delay in treatment.
17. An interview was conducted with the Director of Quality Improvement/Performance Improvement on 5/8/12 at 1400 and she revealed when patient's report to the ED, the registration clerk writes down their name and the time. Then she calls the patient's in order of their arrival and registers them into the PRO-MED system, this alerts nursing there is a patient in the waiting room. If the clerk is busy, there can be delays in the time of arrival and the time of registration. She agreed with the findings in the medical records listed above, and stated the Presentation Time on the front sheet indicates the time the patient was entered into the PRO-MED system, not the arrival time.