HospitalInspections.org

Based on review of hospital documents, medical record, and interviews, it was determined that the hospital governing body failed to require that the medical staff is accountable for the quality of care provided for 1 of 1 patient (Pt #2).

Findings include:

Review of hospital document titled 2010 Medical Staff Bylaws revealed: "...Basic Obligations of Individual Staff Membership...Each staff member, regardless of assigned staff category...shall:...Abide by the Corporate Bylaws, these Bylaws, Medical Staff and Department Rules and Regulations, and all other standards and policies of the Medical Staff and Hospital...."

Review of hospital document titled General Medical Staff Rules and Regulations 2010 revealed: "...Emergency Department and Outpatient (including Observation) records shall include the following when appropriate:...Condition of patient on discharge...."

Review of medical record:

Pr #2 arrived at the Emergency Department (ED) on 3/16/11, at 1735, via emergency medical services (EMS), due to injuries sustained in a motorcycle accident. He was riding without a helmet, lost control of the motorcycle and fell to the right side, hitting his face and right side. He denied loss of consciousness.

Pt #2 was triaged as a "trauma 2" patient and was examined by the ED physician and a trauma surgeon.

Computerized tomography (CT) of the abdomen and pelvis and the lumbar spine were completed and revealed: "...a fracture through the greater trochanter of the right femur with adjacent soft tissue hematoma...." He had multiple abrasions on the right side of his forehead and right side of his face and a 3 centimeter laceration lateral to the right eye.

The trauma surgeon documented the plan to include repair of the laceration; liquid diet and ambulation. "...If he tolerates, he is to be discharged to the care of friends or family...." The plan also included documentation that the trauma surgeon consulted with an orthopedic physician "...who indicated that, if the patient is able to bear weight, he will be able to be discharged and can follow up as an outpatient...."

The trauma surgeon also documented discharge instructions: "...WBAT (weight bearing as tolerated) RLE (right lower extremity)...may benefit from use of cane temporarily...."

Neither the trauma surgeon nor the ED physician documented whether the patient was able to bear weight or ambulate. The medical record did not contain a physician's order for nursing staff to assess the patient's ability to ambulate. Discharge instructions did not contain information regarding how the patient was to obtain a cane or any instruction needed to ambulate with a cane. The medical record did not contain documentation of the patient's discharge condition.

The ED Clinical Coordinator confirmed during interview conducted on 11/21/11 at 1215, that nursing would not assess the patient's ability to ambulate or bear weight without a physician's order to do so. She also confirmed that a physician did not document the patient's ability to ambulate or bear weight.

The Vice President of Quality Management; Compliance and Privacy Officer confirmed during interview conducted on 11/21/11, that whether the patient was treated by a trauma physician or an ED physician, the ED Department Rules and Regulations are applicable. She confirmed that the Rules and Regulations and Medical Staff Bylaws 2010 are the current documents. She also confirmed that Pt #2's medical record from 3/16/11 did not contain physician documentation of the patient's condition at the time of discharge from the ED, including the patient's ability to ambulate or to bear weight on his RLE.

On 3/18/11, the patient returned to the ED at 1320. At 1635, a nurse documented: "...(increased right) hip pain, can't walk now...."

An RN documented that the patient was discharged at 1938 via wheelchair.

Based on review of medical record and interview, it was determined that the hospital failed to require that a registered nurse supervise and evaluate the nursing care for 1 of 2 patients (Pt #2).

Findings include:

(Cross reference Tag A0049 for information regarding Pt #2.)

Review of medical record:

A Health Unit Secretary documented that Pt #2 was discharged home at 2125. Nursing recorded the last set of vital signs at 1930. The last nursing note contained documentation of administration of 2 Percocet tablets at 2015. Nursing documentation did not contain an assessment of the patient's ability to ambulate or ability to bear weight. A nurse did not document the time that the patient was discharged from the ED; whether he required a wheelchair; whether he required assistance with ambulation.

The hospital was unable to provide nursing or ED policy/procedures related to required documentation of the patient's status at the time of discharge. The Clinical Coordinator of the ED stated during interview conducted on 11/21/11 at 1215 that she was unable to provide a written policy/procedure regarding the required ED nursing documentation. However, she stated that the accepted practice and nursing standard of care in the ED includes nursing documentation of a discharge note which would include: the disposition of the patient; patient status such as pain level; whether the patient was ambulatory or not; mention of instructions, and whether the patient was accompanied; and who accompanied the patient. She confirmed that the patient's 3/16/11 ED record did not contain a nursing discharge note or documentation regarding the patient's ability ambulate.