HospitalInspections.org

Based on interview and medical record review, the nursing staff failed to follow the interdisciplinary care plan for the provision of a physician order for a prefabricated splint for 1 of 6 sampled patients (#1).

Findings:

Patient #1's medical record contained the nursing document "Rapid Initial Assessment" indicating the patient arrived at the emergency department (ED) at 5:45 AM on 8/24/22 via Emergency Medical Services. The patient's assessment was left ankle pain today with a pain intensity of 3.

The ED physician's note of 8/24/22 at 5:41 AM read, "Clinical Impression: Primary Impression: Left ankle pain. Secondary impressions: Left ankle swelling . . . Imaging studies without acute findings. Patient re-evaluated found alert and active, symptoms improving. Oriented about results, instructed follow up with primary care physician. Will prescribe prescription for pain medication. Patient understood, agreed to discharge and read back. Patient stable at moment of discharge home."

Physician's orders of 8/24/22 at 7:53 AM read, "Ortho: Prefabricated Splint." There was no evidence in the medical record which showed that this order was fulfilled and provided to patient #1.

On 10/18/22 at 10:20 AM, the Patient Safety Director confirmed the finding.