HospitalInspections.org

Based on observation, staff interview, review of policies, procedures, clinical records and facility documentation it was determined the facility failed to appropriately assess/reassess and discharge 3(#1, #5, and #19) of 20 sampled patients. The facility also failed to ensure patient/visitor safety by securing laboratory specimens, syringes, needles and appropriate monitoring of refrigerator temperatures in the emergency department.
Findings include:
(1) The emergency department(ED) nursing staff did not adhere to the facility's policies for " Patient Care Process ", policy# 100.185.74, and " Emergency Department: Discharge ", policy #09-03-004, for 3 (#1, #5 and #19) of 20 sampled patients, with the end result of the death of 1 (#5) patient. This practice does not ensure ED patients are safely discharged and the emergency medical condition no longer exists. Refer to 1104.
(2) The facility did not ensure laboratory specimens; syringes and hypodermic needles were secured and inaccessible to patients and visitors in the ED. This practice does not ensure patient safety and tampering of ED equipment. Refer to 1101
(3) Observation of the ED nutrition refrigerator thermometer revealed a temperature reading of 44 degrees Fahrenheit (F).A review of the medication Refrigerator Temperature Log for the Month of November 2011 revealed the temperature was not monitored for 10 ( 5-11, 14-16th ) of 16 days. An interview with the ED director revealed she was unsure of the safe range for the refrigerator temperature. Review of policy and procedure and interview with the Director of Food Services on 11/16/11 at approximately 3:00 p.m. revealed the temperature should be less than 40 degrees F and the refrigerator had not been monitored by the dietary department. This practice does not ensure the safe storage of patient food.


The cumulative effect of these practices lead to the facility not being in compliance with the condition of Participation for Emergency Services.

Based on observation, staff interview, and review of policy, procedure, clinical records, and facility documentation it was determined the facility failed to ensure patient/visitor safety by securing laboratory specimens, syringes, needles and failed to appropriately monitor the refrigerator temperatures in the emergency department.

Findings include:

(1)A tour was conducted on 11/16/11 at approximately 12:55 pm of the Main Emergency Department; which revealed an area next to the hallway for laboratory needs. On the counter were 17 vials that contained blood. On a biohazard garbage container lid was a urine specimen container with urine (not bagged). During the observation a mid level practitioner dropped off a urine specimen container (not bagged)on a counter. This area is accessible to ED patients ambulating and visitors. Observation of patient rooms revealed personal care items such as multiple basins and urinals were on the counter or racks all available to the patient or visitors in the room. Observation during tour of the ED fast track area revealed a treatment cart that contained hypodermic needles and syringes. This cart was accessible to ED patients ambulating and visitor.

(2)Observations made during the tour of the main ED conducted on 11/16/11 at approximately 12:55 pm, of the nutrition refrigerator revealed a temperature reading of 44 degrees Fahrenheit (F). A interview with the ED Nurse Director during the tour revealed she was not sure of the safe range for the temperature. Review of the temperature log for 10/11 revealed temperatures were not monitored on 10/2, 10/22, 10/23 and 10/28/11. All monitored days revealed temperatures greater than 40 degrees F. Review of the temperature log for 11/11 revealed temperatures were not monitored from 11/9 to 11/12/11 and 11/15/11. All monitored days revealed temperatures greater than 40 degrees F.

Review of policy and procedure and interview with the Director of Food Services on 11/16/11 at approximately 3:00 p.m. revealed the temperature should be less than 40 degrees F and the refrigerator had not been monitored by the dietary department.

Based on staff interview, review of policies, procedures, clinical records and facility documentation it was determined the emergency department(ED) nursing staff did not adhere to the facility's policies for "Patient Care Process, Assessment/Reassessment, policy# 100.185.74, and "Emergency Department: Discharge", policy #09-03-004, for 3 (#1, #5 and #19) of 20 sampled patients, with the end result of the death of 1 (#5) patient. This practice does not ensure ED patients are safely discharged and the emergency medical condition no longer exists.

Findings include:

(1) Patient #5 presented to the Emergency Department (ED) via ambulance on 10/1/11 at 12:35 a.m. with a chief complaint of a reported seizure and had not taken his seizures medications for seven months. The triage documentation revealed the patient was on 2 liters of oxygen via nasal cannula with a oxygenation level of 100%. The patient's identified problem included at risk for falls.

A review of the physician orders dated 10/1/11 at 2:50 a.m., revealed orders for intravenous (IV) fluids of Normal Saline 1000 milliliters (ml) with multivitamins, thiamine, folic acid, and magnesium sulfate at 125 ml per hours for eight hours. The orders included Ativan 1 milligram (mg) times one, a Dilantin level, and a urine drug screen. Physician orders dated 10/1/11 at 3:39 a.m. instructed for Cerebyx (anti seizure medication)1000 milligrams (mg) one time. Physician orders dated 10/1/11 at 3:41 a.m., revealed orders to "discharge the patient home at 7:00 a.m.. The patient may be discharged home earlier if a sober ride is available".

A review of the initial nursing assessment dated 10/1/11 at 12:46 a.m. revealed the patient was alert, cooperative, and appropriate. The patient was on a cardiac monitor.
The nursing documentation revealed the vital signs were stable at at 3:32 a.m. with 2 liters oxygen via nasal cannula with 100 % saturation. There was no evidence of any other assessment completed. The nursing documentation at 5:44 a.m. noted no blood pressure was obtained, oxygen was administered at 2 liters via nasal cannula with a saturation level of 96%. There was no evidence of any other assessment completed.

A review of laboratory results showed a sub therapeutic Dilantin level and a blood alcohol of 287 (0-5). The urine drug screen was positive for opiates and benzodiazepines.

A review of the Medication Administration Record (MAR) indicated the Cerebyx was completed at 4:18 a.m. and the Ativan at 3:31 a.m. The IV infusion was documented as started at 3:32 a.m. and discontinued at 9:10 a.m. over two hours after the patient had left the facility. The documentation noted 1000 ml's had infused. Based on the time the infusion was started and the patient discharged, the patient should have received approximately 300 ml's.

A review of discharge instructions revealed the instructions were signed by the patient and nurse. The instructions for alcohol intoxication were to drink plenty of non alcoholic fluids and eat regular meals.

A review of nursing documentation did not reveal evidence of the patient being assessed prior to discharge for the oxygen saturation on room air after the oxygen was discontinued (no time), the patient's ability to eat or drink, the ability to ambulate or his mental and neurological status after being intoxicated and receiving Ativan and a loading dose of Cerebyx. There was no evidence the physician was notified that the patient refused discharged vital signs or the IV infusion was not infused as ordered. There was no documentation of how the patient left the ED or if a sober ride was available as ordered.

A review of documentation dated 10/1/11 at 7:10 a.m. and interview with the Risk Manager on 11/15/11 at approximately 4:50 p.m. revealed the patient was given a bus pass on discharge. He left the ED and went to the bus stop located on the campus but on city property. The patient reportedly fell from the curb and fell in front of the bus and expired at the scene.

A interview with the Risk Manager and Director of Patient Services on 11/16/11 at approximately 2:20 p.m. and review of documentation revealed the following. A staff member reported the patient walked into the ED walk in/exit door, then was leaning against the wall and was mumbling. The incident caused the doors to come off their tracks. Another staff member reported the patient seemed wobbly.

The interview and review of the clinical record failed to reveal that the patient who had just been discharged was not assessed for injury or the need to return to the ED.

The nurse did not follow policy and procedure for reassessment and discharge to determine if the patient remained stabilized or to alert the physician if not stable prior to discharge.

(2) Patient #19 presented to the facility on 6/1/11 at 9:23 p.m. with a chief complaint of Seizures. A review of ED physician discharge instructions revealed she was not to drive until follow up with her physician. Review of nursing documentation did not show evidence of how the patient left the ED.

A Interview with a ED nurse on 11/16/11 at approximately 1:00 p.m. confirmed the findings.

(3) Patient #1 presented to the ED on 11/1/11 at 4:15 a.m. with a chief complaint of being unresponsive after drinking. A review of the initial nursing assessment dated 11/1/11 at 4:34 a.m. revealed the patient was lethargic. The ED physician impression was altered mental status and acute alcohol intoxication. Nursing documentation at 12:55 p.m. noted the patient was reassessed and was alert. Nursing documentation at 5:32 a.m. revealed a family member was contacted. a review of discharge instructions revealed the form was signed and dated on 6/1/11 at 1:10 p.m. by the patient. There was no evidence of how the patient was discharged or who was driving.

A review of policy and procedure "Patient Care Process" #100.185.74 effective 8/11 indicated Emergency Department patients are to be reassessed every two hours. A review of policy and procedure "Emergency Department: Discharge" #09-03-004 effective 9/09 indicated patients may be discharged when the vital signs are stable, neurological status is at baseline and the patient is able to care for self. The discharge documentation is to include the date and time of discharge and type.