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Based on interview and record review the Hospital failed for five Emergency Department (ED)
patients (Pt #1, Pt #6, Pt #8, Pt 9, Pt #10) to ensure all the medical interventions provided, were integrated into each of the five ED patient records.


Findings include:

The Hospital Policy and Procedure Titled Moderate Sedation, dated 7/31/20, Section C Brief Operative Note: indicated when a procedure note cannot be immediately placed in the chart, a brief operative or procedure progress note must be placed in the chart before the provider performing the procedure leaves the procedure site.

Patient #1's ED record, dated 7/20/20, indicated he/she received sedation medication for closed management of a left leg fracture. However, there was no procedure note by the provider who performed the closed reduction procedure in the ED.

Patient #6's ED record, dated 7/19/20, indicated he/she received sedation medication for a closed reduction of a left wrist fracture. However, there was no procedure note by the provider who performed the closed reduction in the ED.

Patient #8's ED record, dated 7/22/20, indicated he/she received sedation medication for a closed reduction of a left lower leg fracture. However, there was no procedure note by the provider who performed the closed reduction in the ED.

Patient #9's ED record, dated 7/22/20, indicated he/she received sedation medication for a closed reduction for a right arm fracture. However, there was no procedure note by the provider who performed the closed reduction in the ED.

Patient #10's ED record, dated 7/15/20, indicated he/she received sedation medication for a closed reduction of a right wrist fracture. However there was no procedure note by the provider who performed the closed reduction in the ED.

During an interview with the Associate Chief Nurse for Emergency and Psychiatric Services at 9:30 A.M. on 8/25/20, she indicated a progress note should be documented in the ED record by a provider performing a procedure in the ED.