HospitalInspections.org

Based on document review and medical record review, in 1 of 21 (Patient #1) medical records reviewed, Patient #1 had a a chest x-ray and received a nebulizer treatment on 2/5/2024, but there is no documentation of a provider or nursing assessment related to these interventions.

Findings include:

-- Per medical record review, Patient #1 arrived to the ED on 2/4/2024 at 4:24 pm. Patient #1 was triaged at 4:26 pm with a chief complaint, "brought by daughter who is concerned about pt's (patient's) weight loss of greater than 10 pounds in 3 weeks. Hasn't been sleeping. Patient's wife died 7 weeks ago. Patient. is tearful. Daughter requesting a crisis evaluation as well." Acuity level assigned was 3 on Emergency Severity Index (ESI) (is a 5-level triage system that categorizes emergency department patients by evaluating both patient acuity and the patient care resource needs. Acuity is determined by the stability of vital functions and potential for life, limb, or organ threat).Vital signs were temperature 98.4 degrees Fahrenheit, heart rate 84, respirations 22 (lungs clear, respirations unlabored), oxygen
saturation on room air 95 %.

A physician assistant saw Patient #1 at 5:27 pm. Physical exam revealed Patient #1 was alert and tearful, with normal respiratory effort and no respiratory distress.

A physician saw Patient #1 at 7:15 pm. Review of systems revealed "positive for insomnia, decreased appetite, depression." Medical Decision Making indicated "... Urinalysis not consistent with urinary tract infection. ... " Patient was provided 50 milligrams (mgs) of oral hydroxyzine and 6 mg of oral Melatonin for sleep. Patient was still agitated, needs something else for sleep. Five mgs of intramuscular Haldol provided. Crisis stated that they were able to evaluate the patient and patient will receive a physician evaluation in the morning. Patients disposition is pending crisis recommendations. ED physician's diagnosis was normal grief reaction, insomnia, anxiety, depression and failure to thrive.

On 2/5/2024 at 2:35 am vital signs were temperature 97.5 degrees Fahrenheit, heart rate 80, respirations 18, blood pressure 110/60, and oxygen saturation 96%.

At 4:41 pm: Patient #1 was accepted at Hospital B for transfer for inpatient psychiatric care.

At 5:54 pm: a chest x-ray revealed "Findings suggestive of congestive heart disease with mild bibasilar atelectasis or less likely pneumonia." At 7:55 pm Patient #1 received Albuterol 3 milliliters (mls) nebulizer.

At 9:51 pm vital signs were: temperature 97.5 degrees Fahrenheit, heart rate 86, respirations 18, blood pressure 125/64, and oxygen saturation 97%.

Patient #1 was transferred to Hospital B for a higher level of care.

-- Per review of hospital policy and procedure titled "Patient Assessment & Reassessment: Documentation and Plan of Care," (revised 10/2023), "the purpose of this policy is to provide a process for patient assessment/reassessment to determine the level of care required to meet the patient's initial needs as well as his/her needs as they change in response to care or disease process. ..."

- Per interview of Staff F on 11/5/2024 at 2:00 pm, they acknowledged the above findings.