HospitalInspections.org

Based on document review and interview, the emergency department (ED) physician failed to complete the patient's medical record so as to justify his plan of care.

Findings:

On 6/22/12 a 79 year-old gentleman was brought by ambulance to the ED. The patient had been released from Samaritan Hospital 2 days prior on 6/20/12. The patient had been admitted on 6/18/12 with shortness of breath, hypertension and a Troponin of 0.57. His past medical history was significant for alcohol abuse. He was admitted to a telemetry bed and had a cardiac workup done. He was treated for a non-ST elevation myocardial infarction, pulmonary edema and a new right bundle branch block. On 6/20/12 the patient decided to leave. His attending explained the risks but the patient insisted. The patient promised to return the following Monday to complete nuclear stress testing. The patient was discharged with instructions to fill his prescriptions and to follow up with his primary care physician and the cardiologist. Documentation was clear that the patient was capable of making a decision to leave.

On 6/22/12, the patient had been found on the sidewalk. He did not recall falling. The patient was walking home from having dinner when he had a syncopal episode. At dinner he had had a glass of vodka and 2 glasses of wine. An ambulance brought the patient to the ED. Initially the patient had refused treatment and had wanted to go home. He denied chest and/or head pain. Eventually he agreed to have lab work done. His lab work was within normal limits with the exception of a Troponin of 0.13 and a blood alcohol level (BAL) of 131. Although nursing had written that the patient had a small abrasion to the right orbit, there was no mention by the physician as to the possibility of head trauma and/or the need for a diagnostic work-up.

A physician, board certified in emergency medicine, reviewed the medical record. The reviewer felt more documentation was needed to support the physician's decision making..

The ED physician indicated during an interview on 4/10/13 at 1045, that the patient had been a difficult patient. The patient had initially refused to consent to any medical interventions. As the patient was found to be alert and oriented X3, and his gait steady, the scrape near the patient's right eye, did not appear to be indicative of a head injury.