HospitalInspections.org

Based on review of facility policy and interview with staff (EMP), it was determined the facility failed to ensure that medical care was provided to a patient reporting for emergency services.

Findings include:

A review on March 15, 2012, of Emergency Service Policy and Procedure Manual, Procedure # 18 Assessment and Reassessment of Patients revealed:
" I. Policy: A. Patients presenting to the Emergency Department should be assessed for physical, psychological and social status to identify patient's needs.
B. The patient and family me/b/rs, when appropriate, are included in the assessment process and ongoing care.
C. The Emergency Department will follow hospital wide policy for assessment/reassessment time frames.
II. Procedure: A. Assessment of the emergency department patient shall begin at triage, and should not be delayed in order to obtain financial information.
B. An assessment should be initiated after the patient is placed in the treatment area. The scope and intensity of this assessment is determined by the patient's condition, complaint/diagnosis, the care setting and response to previous care, as well as the patients desire for care."
C. Each patient should have a Medical Screening Examination (MSE) by a physician, physician extender or an RN as approved by hospital bylaws."

A review on March 15, 2012, of the log, "Removed From Presentation" indicated the patient arrived to the ED on March 8, 2012, at 23:16 and left at 00:18. Reason: "Left during presentation". There was no documentation to indicate the patient received an assessment.

An interview conducted on March 15, 2012, at 2:00 PM with EMP4 confirmed that facility policy was not followed and that the patient was not triaged or seen and treated by a physician.

Based on review of facility Rules and Regulations, facility policy, documentation and interview with staff, it was determined the facility failed to provide a medical screening to a patient who presented to the Emergency Department (ED).

Findings include:

A review on March 15, 2012, of Medical Staff Rules and Regulations, dated November 2011 revealed, "5.1(a) Screening (1) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine that the individual is experiencing an emergency medical condition".

A review on March 15, 2012, of Emergency Department policy, Assessment and Reassessment of Patients, last reviewed 11/4/11 revealed, "Policy: A. Patients presenting to the Emergency Department should be assessed for physical, psychological and social status to identify patient's care needs".

A review on March 15, 2012, of the log, "Removed From Presentation" indicated the patient arrived to the ED on March 8, 2012, at 23:16 and left at 00:18. Reason: "Left during presentation".

An interview conducted on March 15, 2012, at 2:00 PM with EMP4 confirmed the patient was not triaged or seen and treated by a physician.

Based on review of Chestnut Hill Hospital Rules and Regulations, facility policy, documentation and interview with staff (EMP), it was determined the facility delayed the treatment of a patient presenting to the Emergency Department.

Findings include:

A review on March 15, 2012, of Medical Staff Rules and Regulations, dated November 2011 revealed, "5.1(a) Screening (1) Any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine that the individual is experiencing an emergency medical condition".

A review on March 15, 2012, of Emergency Department policy, Assessment and Reassessment of Patients, last reviewed 11/4/11 revealed, "Policy: A. Patients presenting to the Emergency Department should be assessed for physical, psychological and social status to identify patient's care needs".

A review on March 15, 2012, of the log, "Removed From Presentation" indicated the patient arrived to the ED on March 8, 2012, at 23:16 and left at 00:18. Reason: "Left during presentation".

An interview conducted on March 15, 2012, at 2:00 PM with EMP4 revealed there was an unusually high volume of patients presenting to the Emergency Department that evening.
EMP4 confirmed that the patient left the facility prior to being triaged or seen and treated by a physician.