HospitalInspections.org

A. Based on review of medical records, review Policies and Procedures, the Emergency Room Register (ERR), Ambulance Radio Log Book and staff interview, it was determined the Hospital failed to document all patients on a central log when presenting to the Hospital ED, refer to A2405. The Hospital failed to provide an appropriate Medical Screening Examination (MSE) to all patients that presented to the ED, refer to A2406. The Hospital failed to ensure an appropriate transfer process was followed, refer to A2409.

A. Based on Hospital policy, a review of internal documentation, Emergency Room Register (ERR) and staff interview, it was determined that in 1 of 20 (Pt #1), Emergency Department (ED) records reviewed, the Hospital failed to ensure all patients that presented to the ED were included on the ERR.

Findings include:

1. The Hospital policy "ER LOG" (reviewed 4/03) was reviewed on 4/9/12. Documentation indicated "The ER register will be maintained and contain the following information on each patient: 1. Name, age, sex, 2. ER number, 3. Time, date and means of arrival..."

2. The Hospital's internal documentation was reviewed on 4/9/12. Documentation on the
"Emergency Department Communications Record" on 3/28/12 at 1111 indicated a 75 year old female was enroute to the Hospital and upon arrival at 1118 the EMS was instructed to take patient to another Hospital for a psychiatric evaluation because "she was seen here yesterday, treated and released."

3. The Hospital ERR was reviewed on 4/9/12. Documentation indicated Pt. #1 was admitted to the ED via EMS on 3/27/12 with chief complaint of Hypoglycemia and Mild Dehydration. Documentation indicated that Pt. #1 was treated and released back to the Long Term Care facility. There was no documentation on the ERR to indicate Pt. #1 presented to the ED on 3/28/12.

4. During an interview with the Chief Nurse Executive (CNE) and ED Supervisor on 4/9/12 at 3:00 PM, the CNE and ED Supervisor confirmed the patient referred to on the "Emergency Department Communications Record" on 3/28/12 was Pt. #1. All above findings were confirmed.

A. Based on a review of internal documentation, EMS documentation, review of medical record from receiving hospital, and staff interview, it was determined that in 1 of 20 (Pt #1), ED records reviewed, the Hospital failed to ensure all patients that presented to the ED were provided with a Medical Screening Examination (MSE).

Findings include:

1. The "Emergency Department Communications Record" was reviewed on 4/9/12. Documentation indicated at 1111 a 75 year old female was enroute to the Hospital and upon arrival at 1118 the EMS was instructed to take patient to another hospital for a psychiatric evaluation because "she was seen here yesterday, treated and released."

2. The EMS documentation was reviewed on 4/9/12. Documentation indicated that EMS was dispatched to the Long Term Care facility on 3/28/12 at approximately 1100 to transport Pt. #1 for a chief complaint of Left shoulder pain due to a fall. Documentation indicated Pt. #1 was transported to the hospital and upon arrival was told that Pt. #1 should go to the receiving hospital for a psychiatric evaluation. There was no documentation that a MSE was completed at the hospital.

3. During an interview with the ED physician on 4/9/12 at 3:30 PM, the ED physician confirmed that a MSE was not completed on Pt. #1. The ED physician stated that Pt. #1 was supposed to go to the receiving hospital for a psychiatric evaluation. The ED physician stated that the vital signs and stabilization of Pt. #1 was discussed with EMS. The ED physician stated Pt. #1 was safe for transfer and there was no emergency medical condition. The ED physician stated that the Primary Care Physician (PCP)was notified and agreed that Pt. #1 should be transferred to the receiving hospital for a psychiatric evaluation.

4. During an interview with the PCP on 4/9/12 at 3:45 PM, the PCP confirmed that Pt. #1 had arrived to the Hospital ED, but should have gone to the receiving hospital for psychiatric evaluation. The PCP stated that the ED physician had conversed and discussed Pt. #1's condition. The PCP stated that Pt. #1 did not have an emergency medical condition and only needed a psychiatric evaluation.

5. During a telephone interview with the Ambulance Director on 4/10/12 at 10:45 AM, the Ambulance Director confirmed that upon the arrival of Pt. #1 to the Hospital on 3/28/12 at approximately 1118, the EMS crew were told that Pt. #1 should not be here. The EMS crew were told that Pt. #1 was supposed to go to the receiving hospital for a psychiatric evaluation. The Ambulance Director confirmed that the EMS crew had no knowledge of a psychiatric evaluation. The EMS was dispatched to the Long Term Care facility for a "fall". The Ambulance Director confirmed that the ED physician assessed the vital signs that the EMS had taken and asked if Pt.#1 was comfortable. The ED physician then directed the EMS to take Pt. #1 to the receiving hospital.

6. The medical record of Pt.#1 from the receiving hospital was reviewed on 4/9/12. documentation on the "Emergency Department Nursing Record" from the receiving hospital indicated Pt. #1 was triaged at 1246 on 3/28/12. Documentation indicated P-156, R-24, BP-139/119, O2 Sat-82% with O2-2 liters/minute per nasal cannula. Documentation indicated Pt. #1 arrived via EMS "due to refusal at (transferring hospital)". Pt. #1 was "alert to name/place, confused at times, combative, very anxious. Pt. #1 was complaining of severe pain to left shoulder, arm, and hand". Pt. #1 was treated and admitted to the Medical Surgical unit. There was no documentation in the medical record at the receiving hospital to indicate Pt #1 received a MSE by the transferring hospital,was instructed on risks/ benefits of transfer, had transfer information sent, or that the receiving hospital was contacted by the transferring hospital for acceptance of Pt #1.

7. During an interview with the CNE and ED Supervisor on 4/9/12 at 3:00 PM, the above findings were confirmed.

A. Based on internal documentation, medical record review from receiving hospital, and staff interview, it was determined that in 1 of 6 (Pt #1) medical records reviewed in which the patient was transferred, the Hospital failed to ensure transferring patients receive stabilizing treatment, documented the risks and benefits associated with the transfer, contacted a receiving hospital for an acceptable transfer from the Emergency Department (ED).

Findings include:

1. The internal documentation from the hospital was reviewed on 4/9/12. Documentation on the "Emergency Department Communication Record" indicated that on 3/28/12 at 1111 a 75 year old female was enroute to the Hospital and upon arrival at 1118 the EMS was instructed to take patient to another Hospital for a psychiatric evaluation because "she was seen here yesterday, treated and released."

2. During an interview with the ED physician on 4/9/12 at 3:30 PM, the ED physician confirmed that a transfer was not completed on Pt. #1. The ED physician stated that Pt. #1 was supposed to go to the receiving Hospital for a psychiatric evaluation. The ED physician stated that the Primary Care Physician (PCP) was notified and agreed that Pt. #1 should be transferred to receiving hospital for a psychiatric evaluation. The ED physician indicated that the ED physician did not contact the receiving Hospital for acceptance and transfer of Pt. #1.

3. The medical record of Pt.#1 from the receiving hospital was reviewed on 4/9/12. Documentation on the "Emergency Department Nursing Record" from the receiving hospital indicated Pt. #1 was triaged at 1246 on 3/28/12. Documentation indicated Pt. #1 arrived via EMS "due to refusal at (the transferring hospital)". Pt. #1 was treated and admitted to the Medical Surgical unit. There was no documentation in the medical record at the receiving hospital to indicate Pt #1 was instructed on risks/ benefits of the transfer, or that the receiving hospital was contacted by the transferring Hospital for acceptance of Pt #1.

4. During an interview with the CNE and ED Supervisor on 4.9/12 at 3:00 PM, the above findings were confirmed.