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Based on interviews and record review the facility failed to ensure the needs of the patient were met within the emergency department (ED) in 1 out of 2 mental health hold records reviewed (Patient #4).

The failure created the potential for unmet patient needs and comfort measures which contribute to a sense of safety and well being.

Findings:

Policy

The policy, Emergency Department Protocol, Care of the ED Patient, states that all patients will be re-assessed at least on an hourly basis and the assessment will be documented in the patient's record.

1. The facility failed to ensure the care needs of Patient #4 were met in the ED.

a) On 9/12/15 at 12:11 p.m., Patient #4 was admitted to the ED for symptoms of dizziness, nausea, and a loss of control of body movements (ataxia) along with making "bizarre" physical complaints. A medical screening examination was performed including laboratory and radiological testing. Patient #4 was determined to be free of any medical concerns.

The treating emergency physician determined Patient #4 was experiencing decreased psychological stability and placed Patient #4 on an involuntary mental health hold at 4:45 p.m. Patient #4 was released from the involuntary mental health hold at 8:06 p.m. on 9/12/15 and discharged from the ED at 8:45 p.m., 8.5 hours after his/her arrival.

b) Review of the Patient Notes, dated 09/12/15, showed Patient #4 requested fluids at 2:36 p.m. and the physician was notified of the request. There was no documentation the patient was provided fluids. Furthermore, there was no documentation within the ED record to show the patient was provided or offered fluids or food during his/her 8.5 hour visit to the ED. There was no physician's order to show the patient could have "nothing by mouth" or documentation which explained why the patient was not offered fluids during his/her ED visit.

A security officer was assigned to monitor Patient #4 and documented behavior/activity codes on the Patient Assist Report every 15 minutes. Review of the Report, dated 09/12/15, completed by security and co-signed by Registered Nurse (RN) #5, showed Patient #4's needs were assessed every 15 minutes. Activity code 9, on the report, was titled Nutritional needs and was used to document the patient's nutritional needs had been addressed. There was no documentation the patients nutritional needs, including the request for water, were addressed. Specifically, activity code 9 was never documented as completed.

c) On 10/14/15 at 12:47 p.m., the ED Nurse Manager (NM #5) was interviewed and stated "I would think the nurse would offer" oral intake. NM #5 stated "I cannot confirm, according to the record that [Patient #4] was offered fluids".