HospitalInspections.org

Based on patient medical record review and policy and procedure review, the facility failed to ensure that the ED (emergency department) staff implemented its policy related to the documentation of a patient's emergency severity index level on the medical screening exam form, and failed to implement its policy related to continuous monitoring of an ED patient, for one patient medical record reviewed. (pt. N1)

Findings:
1. at 10:15 AM on 8/5/10, review of the policy and procedure: "Triage and MSE (Medical Screening Exam), File No.: EDS - 002-P, reads:
a. in section II. under "Procedure (if applicable): Ambulatory Patients": "...3. The Primary Triage RN (registered nurse) will begin the MSE (medical screening exam). 4. If it is determined the patient requires resuscitation (Level 1) or has an emergent (Level 2) condition, they will be transported directly back to a room by the staff where immediate assessment and care will be provided. 5. If it is determined that the patient has an urgent (Level 3), non-urgent (Level 4) or referred (Level 5) condition, the MSE and Medication Reconciliation will be completed by an RN and EDT (emergency department technician) at triage..."

2. at 10:15 AM on 8/5/10, review of the policy and procedure: "EMTALA - Medical Screening Examination, Stabilization, Transfer, Signage, Log, Provision of On-Call Coverage, Duty to Accept Transfers", File No.: ADM-CC-1-P, reads:
a. on page 6 of 13: "D. How to Provide the Medical Screening Examination...6. A Medical Screening Examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred..."

3. at 10:10 AM on 8/6/10 review of patient medical records indicated:
a. pt. N1 had:
A. a medical screening exam done on 7/18/10 that is lacking documentation on the Triage/MSE form of a level of care selection (Level 1 through 5) needed to determine appropriate placement in the ED
B. a one hour break in the documentation of "continued monitoring", as per the policy in 2. above, between 1500 hours when nursing documentation indicated a CCMS (clean catch midstream) urine specimen was obtained and 1600 hours when the patient was noted as "not in room".

4. it could not be determined, as a level of care was not selected, what constituted "continued monitoring according to the patient's needs" as the policy states for N1.