HospitalInspections.org

Based on medical record review and staff interviews it was determined that Staff #1 failed to document his phone conversation with the facility surgeon regarding Patient #1.

-Review of the Nursing Documentation, 131B, revealed at 16:32 the CT scan report is received from Foundation Radiology Group that revealed "large hematoma involving the inferior right rectus abdominis muscle with an area of presumed active bleeding/active contrast extravasation."

-Telephone interview with Staff #4, ED Nurse Manager at Bertrand Chaffee Hospital, on 01/10/12 revealed that Staff #1, the ED physician, consulted with Staff #2, surgeon on call at Bertrand Chaffee, who recommended that the patient be sent to ECMC.
Staff #1 did not document in the record the consult with the surgeon. Staff #4 confirmed that there was no documentation about this consult in the record.