HospitalInspections.org

Based on Medical Staff Bylaws, policies/procedures, medical record review and staff interviews, it was determined Emergency Department Physician #5 failed to:

1. notify the patient's obstetrician (OB) of the patient's arrival to the emergency department (ED); and

2. explain/document the patient's condition prior to her discharge home for 1 of 1 patient (Patient #2).

Findings include:

Patient #2 arrived to the emergency department 09/04/11, with abdominal pain and vaginal bleeding, according to the medical record. The ultra sound revealed: gestational age of 21 weeks; single live intrauterine pregnancy; cardiac activity of 135; IMPRESSION: incompetent cervix.

Physician #5 documented: "The viability is not possible anyway."

2010 Medical Staff Bylaws require: "...basic obligations...each staff member...shall...provide continuous care...at the level of quality and efficiency...recognized as appropriate...."

1. Hospital policy titled "Assessment-Pre-Term Labor" requires: "...Antepartum patients less than 36 weeks pregnant...obtain an obstetrical history...find name and phone number of patient's OB if they have one, and notify...."

Review of Patient #2's medical record revealed: follow with GYN (gynecologist) today Dr. (illegible). The patient's physician was identified, however, there was no documentation the patient's obstetrician was notified.

The Medical Director and the Quality Management VP confirmed during an interview conducted on 08/14/12, that there was no documentation in the medical record that the ED physician notified the patient's obstetrician of her arrival or condition.

2. Hospital policy titled "Overview-Screening for Medical Emergencies and Patient Transfer" requires: "...patients...gestational age...greater than 18 weeks...released with appropriate directions...."

Hospital policy titled "Patient's Rights" requires: "...Right..talk...and participate in decisions...receive information...care and condition and answers...."

The "General Instructions for Follow-Up Care" document covers a total of 30 possible diagnosis listed in alphabetical order. Each diagnosis includes a line in front for a check mark to indicate the patient's diagnosis. The patient is to be given the instruction sheet that identifies the patient's diagnosis. These instruction sheets contain general information for the patient with the following explanations: what the diagnosis is, why the condition occurs, signs and symptoms, and how the condition is treated.

ED Director and RN #8, confirmed during an interview conducted 08/15/12, the patient was to receive the instruction sheet titled "Threaten Miscarriage" at discharge, however, there is no documentation in the patient's medical record indicating the patient received the information.

Based on review of hospital documents, medical record, and staff interview, it was determined the nurse executive failed to require the patient's pain level of 10 out of 10 was addressed for 1 of 1 patient (Patient #2).

Findings include:

The facility's Pain Management Protocol requires: "...Assessment...establish a pain goal...determine acceptable level...consult...physician...for pain control...offer pain medications...."

Hospital policy titled "Patient Rights" requires: "...right to have your pain treated...effectively...play a role...how your pain is managed...."

The patient's emergency record dated 09/04/11, revealed: the patient arrived at 0208 hours.

The Nursing Assessment sheet revealed a numeric pain intensity scale of 0: meaning no pain and 10: the worst imaginable pain. The assessment time at 0240 hours revealed the patient's pain score documented 10 of 10; left sided abdominal pain.

The pain score documented at 0345 hours and 0500 hours was 10 of 10.

The Quality Management VP and the Director of the ED confirmed during an interview conducted 08/14/12 and 08/15/12, that there was no documentation in the patient's medical record that the patient's pain was reported to the physician. There is no documentation that the physician ordered or denied the patient pain medication. There is no documentation the patient's pain was addressed.