HospitalInspections.org

Based on record review and interview, the hospital failed to include 1 of 2 patients (#1) in the development of Patient #1's plan of care.

Findings include:

Care plan for Patient #1 dated 2/18/2016 in FYI [for your information] section, revealed a behavioral care plan for Caregiver/Family (H).

During an interview on 10/24/2016 at 11:25 AM, Emergency Room Educator C stated the FYI care plan for Caregiver/Family (H) reoccurs and follows Patient #1 for each emergency room visit. Educator C stated the care plan was not discussed with Patient #1 or Patient #1's family and that the hospital does not have a process in place for sharing the FYI care plan information with the patient or the patient's caregiver/family.

Based on record review and interview, Emergency Department (ED) facility staff failed to provide nursing assessments in the Emergency Department for 1 of 10 patients (Patient #5), and failed to monitor patient condition in the ED per policy for 5 of 10 patients reviewed (Patient #1, Patient #5, Patient #6, Patient #7, Patient #8).

Findings:
Facility policy "Emergency Services Assessment & Documentation Standards" dated July 2013 states: "...e. A Registered Nurse (RN) assessment will be performed for each patient...ii. An initial assessment should be completed on all patients being seen in the [Emergency Services] by the primary RN. Assessment on the following will be focused, based on the patient's presenting complaint or reason for visit...Discharge vitals: need to be done on all patients thirty minutes prior to departure from the [Emergency Services]...Reassess pain and vitals within 30 minutes of departure..."

Per medical record review on 10/24/2016, Patient #5 presented to the ED on 10/10/2016 at 8:20 AM with seizure-like activity. Patient #5's medical record does not include documentation of an initial nursing assessment or focused neurological assessment. Patient #5 was discharged to home from the ED at 12:52 PM. Patient #5's last set of vitals was obtained at 11:45 AM, more than 30 minutes prior to discharge.

Per medical record review on 10/24/2016, Patient #6 presented to the ED on 10/10/2016 at 7:45 PM with loss of consciousness. Patient #6 was discharged from the ED at 9:41 PM. Patient #6's last set of vitals was obtained at 8:45 PM, more than 30 minutes prior to discharge.

Per medical record review on 10/24/2016, Patient #7 presented to the ED on 10/11/2016 at 4:25 AM with seizure-like activity. Patient #7 was discharged to home from the ED at 7:06 AM. Patient #7's last set of vitals was obtained at 6:00 AM, more than 30 minutes prior to discharge.

Per medical record review on 10/24/2016, Patient #8 presented to the ED on 10/14/2016 at 2:14 PM with seizure-like activity. Patient #8 was discharged to home from the ED at 4:46 PM. Patient #8's last set of vitals was obtained at 3:00 PM, more than 30 minutes prior to discharge.

The medical record findings for Patients #5, #6, #7 and #8 were confirmed at the time of review on 10/24/2016 between 11:35 AM and 1:05 PM with ED Director D and ED Manager G. Manager G stated on 10/24/2016 at 12:25 PM that all patients should have vitals signs documented per policy. Director D stated during an interview on 10/24/2016 at 1:30 PM that all patients presenting with seizure-like activity would be expected to have a neurological assessment.







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Review of Emergency Services Policy on 10/24/2016 at 2:20 PM under Emergency Services Records states "final disposition will be documented by the physician". The Emergency Room medical record findings for patient #1 on 10/24/2016 at 11:25 AM were confirmed with Assistant Nurse Manger G at 10/24/2016 at 4:17 PM. Provider notes state "Disposition: Data Unavailable".

During an interview on 10/24/2016 at 4:17 PM with Assistant Nurse Manager G, Manager G stated that more information on patient's mobility status should have been documented.

Based on record review and interview, Emergency Department (ED) facility staff failed to provide nursing assessments in the Emergency Department for 1 of 10 patients (Patient #5), and failed to monitor patient condition in the ED per policy for 5 of 10 patients reviewed (Patient #1, Patient #5, Patient #6, Patient #7, Patient #8).

Findings:
Facility policy "Emergency Services Assessment & Documentation Standards" dated July 2013 states: "...e. A Registered Nurse (RN) assessment will be performed for each patient...ii. An initial assessment should be completed on all patients being seen in the [Emergency Services] by the primary RN. Assessment on the following will be focused, based on the patient's presenting complaint or reason for visit...Discharge vitals: need to be done on all patients thirty minutes prior to departure from the [Emergency Services]...Reassess pain and vitals within 30 minutes of departure..."

Per medical record review on 10/24/2016, Patient #5 presented to the ED on 10/10/2016 at 8:20 AM with seizure-like activity. Patient #5's medical record does not include documentation of an initial nursing assessment or focused neurological assessment. Patient #5 was discharged to home from the ED at 12:52 PM. Patient #5's last set of vitals was obtained at 11:45 AM, more than 30 minutes prior to discharge.

Per medical record review on 10/24/2016, Patient #6 presented to the ED on 10/10/2016 at 7:45 PM with loss of consciousness. Patient #6 was discharged from the ED at 9:41 PM. Patient #6's last set of vitals was obtained at 8:45 PM, more than 30 minutes prior to discharge.

Per medical record review on 10/24/2016, Patient #7 presented to the ED on 10/11/2016 at 4:25 AM with seizure-like activity. Patient #7 was discharged to home from the ED at 7:06 AM. Patient #7's last set of vitals was obtained at 6:00 AM, more than 30 minutes prior to discharge.

Per medical record review on 10/24/2016, Patient #8 presented to the ED on 10/14/2016 at 2:14 PM with seizure-like activity. Patient #8 was discharged to home from the ED at 4:46 PM. Patient #8's last set of vitals was obtained at 3:00 PM, more than 30 minutes prior to discharge.

The medical record findings for Patients #5, #6, #7 and #8 were confirmed at the time of review on 10/24/2016 between 11:35 AM and 1:05 PM with ED Director D and ED Manager G. Manager G stated on 10/24/2016 at 12:25 PM that all patients should have vitals signs documented per policy. Director D stated during an interview on 10/24/2016 at 1:30 PM that all patients presenting with seizure-like activity would be expected to have a neurological assessment.







37419

Review of Emergency Services Policy on 10/24/2016 at 2:20 PM under Emergency Services Records states "final disposition will be documented by the physician". The Emergency Room medical record findings for patient #1 on 10/24/2016 at 11:25 AM were confirmed with Assistant Nurse Manger G at 10/24/2016 at 4:17 PM. Provider notes state "Disposition: Data Unavailable".

During an interview on 10/24/2016 at 4:17 PM with Assistant Nurse Manager G, Manager G stated that more information on patient's mobility status should have been documented.