HospitalInspections.org

I. Based on review of Medical Staff Bylaws,
complainant review, administration interviews
and medical record review, the hospital
failed to follow current Medical Staff Bylaws
in coordinating patient's care. This was
observed in 1 of 6 records, noted in (P1)
Emergency Department (ED) record.

Failure to follow current Medical Staff Bylaws
in coordinating patient's medical care with
nursing care fails to assure that patient's
health care needs will be met.

Findings:

1. On 04/08/2010 at 10:30 AM, the investigator
reviewed the current Medical Staff Bylaws that
were revised in 2007. The review determined
that on page 15, in section J the provider was
to coordinate patients medical care with patient's
nursing care.

2. On 04/08/2010 at 11:00 AM, the investigator
reviewed P#1's ED medical record. The review
determined the triage nurse documented that
patient arrived by ambulance to the ED on
12/27/2009 at 12:10 PM. The Triage nurse
entry documented the 60 year old patient was
going to the car when patient fell to the ground.
The patient claimed s/he could not bear weight
on left leg. Also, patient reported having pain
at left leg thigh, pain at left wrist, and hit face
on a ladder.

3. The Triage nurse also documented the patient
was a diabetic with neuropathy problems and
was insulin dependent. Patient reported s/he
had not taken her/his insulin today. Patient's blood sugar levels usually measured in the 600's.

4. On 04/08/2010 at 12:30 PM, the investigator
interviewed the ED physician who cared
for the patient on 12/27/2009. The ED physician
documented on the provider's record that
patient had history of diabetes with neuropathy
problems and had hypertension.
ED physician documented that patient's left
knee had normal range of motion that
measured from 0-40 degrees.
During the interview the ED physician reported
the patient's blood sugar was not assessed
and patient did not complaint of left hip pain.

5. During an interview with the ED nurse on
04/08/2010 at 2:00 PM. ED nurse reported
that ED staff could monitor patient's blood
sugar/Accu-Checks. The ED nurse reviewed
P#1's ED record and reported that patient's
blood sugar/Accu-Checks were not monitored.

6. Also, the Clinical Nurse Manager reviewed
the record and confirmed that patient's blood
sugar/Accu-Checks had not been done.
The manager confirmed that patient's blood
sugar should have been monitored and
documented on the record.

Based on administration interviews and
medical records review, the hospital failed
to document pertinent patient assessments
in 3 of 6 Emergency Department records,
noted in P2, P3 and P6 Emergency
Department (ED) records.

Failure to monitor and reassess patient's
vital signs fails to ensure that nursing was
assessing patient's change in condition.

Findings:

1. On 04/08/2010 at 1:00 PM, P2's
ED record was reviewed. Triage RN
documented the patient was 70 year old
who presented to ED on 03/02/2010 at
6:53 AM with family members.
The patient reported falling 2 days ago
onto his/her knee. The ED nurse
documented on 03/02/2010 at 6:53 AM
that patient's initial vital signs were as
follows: Patient's blood pressure
measured 173/111 and pulse measured
91. Review of nursing documentation
noted on Emergency Nursing Record
determined that nursing did not reassess
patient's vital signs before patient was
discharged.

2. Director of Nursing and Clinical
Manager confirmed that patient's vital
signs were not reassess and documented
on the record before patient was discharged.

3. During the interview the investigator asked,
if a policy was available for review that
described nurses were to document patient's
vital signs before discharge. They replied
there was not a written policy that identified
this requirement however, it was a nursing
expectation.

4. On 04/08/2010 at 2:30 PM, P#3's ED
record was reviewed. The Triage RN
documented that the 63 year old patient
reported having stabbing knife pain
in back and blood was in urine. The ED nurse
documented that patient's initial vital signs
were as follows: Blood pressure measured
141/82, pulse measured 84, respirations
measured 18 and oxygen saturation
measured at 79% (abnormal value).
The review continued to document that
patient's vital signs and oxygen saturation
measurements were not reassessed before
patient was discharge to home.

5. On 04/08/2010 at 4:00 PM, P#6's
Emergency Nursing Record was reviewed.
The triage entry on 02/05/2010 documented
that patient was 35 years old. The patient
presented to the ED with complaints of
twisting his/her right ankle. The nurse
documented that patient's initial vital
signs measured: blood pressure 154/103,
(abnormal) pulse was 88 and respiration
was 16. Further review indicated that
nursing did not reassess patient's vital signs
and failed to document them on record
before discharge.