HospitalInspections.org

Based on documentation in 11 of 12 medical records reviewed (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) it was determined that the hospital failed to ensure that all entries on consent forms, ED records, discharge instructions, physician orders, and other documents in the medical records were legible, complete, dated, timed, or authenticated.

Findings include:

1. The medical record of Patient 2 reflected the patient presented to the ED on 05/23/2013. All entries in the record had not been authenticated or dated or timed.
*There was no date and time for either the patient's signature or the witness's signature on the Conditions of Admission form.
* There was no date and time for the patient's signature and no time for the RN's signature on the Patient Care Instructions form.
* The Medication Reconciliation Form had multiple entries, including altered entries, that were not authenticated, dated, and timed.
* Multiple different times were recorded for the patient's discharge from the ED. The Patient Care Instructions form reflected a discharge time of 1824; the RN Progress Notes reflected that the patient was discharged at 1841; the Outpatient Admission form reflected that the discharge time was 1925; and the "embrace CARE" triage and treatment form discharge time had been altered from 1842, which had been crossed out, to a time after 1900 that was partially legible. There was no explanation for the discharge time discrepancies.

2. The medical record of Patient 3 reflected the patient presented to the ED on 05/31/2013. All entries in the record had not been authenticated or dated or timed.
*There was no date and time for either the patient's signature or the witness's signature on the Conditions of Admission form.
* The Emergency Transfer Form lacked the times of the signatures of the RN and the physician.
* The Heparin Protocol Orders form which contained physician orders was not authenticated or dated or timed by the physician.
* The "embrace CARE" triage and treatment form contained numerous entries that had been altered as they had been scribbled out or written over, and were rendered unreadable or illegible. Those included VS, times of treatment or medication administration, and medication dosage.

3. The medical record of Patient 4 reflected the patient presented to the ED on 04/02/2014 and was admitted to the hospital as an inpatient through 04/10/2014. All entries in the record had not been authenticated or dated or timed.
* The Emergency Physician Record lacked the date and time it was completed and authenticated.
* Three pages of Admission Orders lacked the date and time of the physician's orders.
* A Consent-Procedural Treatment form for a "chest tube" was lacking the physician's signature as required by the form.
* The chest tube consent form above lacked the time of the patient's and witness's signatures.
* The Emergency Department Procedural Sedation Record did not include a full date for the procedure as it was recorded as "4/6", and the form was not dated or authenticated by the author.

4. The medical record of Patient 6 reflected the patient presented to the ED on 04/06/2014. All entries in the record had not been authenticated or dated or timed.
*There was no date and time for either the patient's signature or the witness's signature on the Conditions of Admission form.
* The Emergency Transfer Form lacked the dates and times of the signatures of the RN and the physician.
* The Heparin Infusion Protocol form which contained physician orders was not dated or timed by the physician.
* The triage level on the "embrace CARE" triage and treatment form had been altered as it had been scribbled over.
* The Emergency Physician Record lacked the date and time it was completed and authenticated and contained an entry that had been altered as it had been scribbled out.

5. The medical record of Patient 7 reflected the patient presented to the ED on 04/06/2014. All entries in the record had not been authenticated or dated or timed.
* There was no date and time for either the patient's signature or the witness's signature on the Conditions of Admission form.
* The Emergency Transfer Form lacked the times of the signatures of the RN and the physician, and the date of the physician's signature had been altered as it had been written over.
* The Emergency Physician Record lacked the date and time it was completed and authenticated.
* The Medication Reconciliation Form had multiple entries, including altered entries, that were not authenticated, dated, and timed.

6. The medical record of Patient 11 reflected the patient presented to the ED on 02/10/2014 and was admitted to the hospital as an inpatient through 02/12/2014. All entries in the record had not been authenticated or dated or timed.
* The untitled triage and treatment record lacked the ED discharge date and time.
* Entries on the Physician Orders forms for orders dated 02/10/2014 and 02/11/2014 lacked the time of the order or the time was not legible.
* A Consent-Procedural Treatment form for an "EGD" was lacking the date and times of the patient representative's and physician's signatures as required by the form.
* The time on a post-surgery checklist had been altered.
* The EGD/Colonoscopy Procedure Record was not authenticated, dated, and timed by the author of the entries on the form.

7. Similar findings were identified in the records of Patients 1, 5, 8, 9, and 10.

Based on interview and documentation in 4 of 8 medical records reviewed of patients who presented to the ED (Patients 2, 5, 7, and 8), and review of policies and procedures, it was determined that the hospital failed to fully develop and implement policies and procedures to ensure that patient vital signs and blood glucose levels were assessed and monitored throughout the ED visit as indicated by the patient's condition.

Findings include:

1. The hospital policy and procedure titled "Emergency Department Admission, Assessment, Reassessment and Hospital Admission", last dated "[January 2013]", was reviewed. It included the following: "Individualized, goal directed nursing care is provided to all patients, considering each patient's physical...status. The scope and intensity of any further assessments are based on the patient's diagnosis...and the patient's response to any previous care...Triage category be assigned...Reassessment will occur when patients or significant others needs change..."

In regards to VS specifically the policy and procedure required that "Vital signs will be recorded...this includes patients in the waiting room...Every 15 minutes for level 1...Every 15-30 minute level 2-3 (unstable vs)...Every 1 hour for level 3-5 (stable vs)". On the triage scale of "1" to "5", "1" is indicative of patients with the most urgent needs. According to the policy there were no provisions for VS any less frequently than every hour.

2. The ED record of Patient 2 reflected the patient presented to the ED on 05/23/2013 at 1610 with a chief complaint of right thigh pain. Triage notes recorded on the "embrace CARE" triage and treatment form by the RN at 1625 identified that the patient was a triage level "2".

VS recorded on the "embrace CARE" form at that time included an increased HR of 99, a low BP of 74/31 and low SaO2 of 92%. The Clindoc Patient Report reflected that the next set of VS taken was at 1800 but did not include the patient's HR. There were no other VS documented in the record after that.

The Lab Summary reflected that blood was drawn for labwork at 1659. The summary reflected that the blood glucose level was reported to be "536 [high critical]" where a normal range was 74 to 106. A note on the Lab Summary reflected "Called glucose to [staff] in ER, read back. Critical results released 05/23/2013 1749 by [staff]". The "embrace CARE" form reflected that the patient was given 20 units of regular insulin at 1835 for "poorly controlled" diabetes and that the physician ordered a "sliding scale" insulin regimen for the patient to manage at home. There was no other documentation of patient blood glucose levels, either by a blood draw or by a fingerstick CBG, to evaluate the results of the insulin.

The time the patient was discharged from the ED was not clear. The Patient Care Instructions record reflected a discharge time of 1824; the RN Progress Notes reflected that discharge instructions were given and the patient was discharged at 1841; the Outpatient Admission form reflected that the discharge time was 1925; and the "embrace CARE" form discharge time had been altered from 1842, which had been crossed out, to a time after 1900 that was partially legible. There was no explanation for the discharge time discrepancies.

There was no documentation of VS for Patient 2 from 1625, for 1 hour and 35 minutes, until 1800; and after 1800 for 1 hour and 25 minutes when the patient was discharged at 1925, the latest time documented as the discharge time. In addition, there was no evidence that the patient's blood glucose level was reassessed prior to discharge.

3. The ED record of Patient 5 reflected the patient presented to the ED on 03/13/2014 at 2036 with a chief complaint of chest pain. Triage notes recorded on an untitled triage and treatment form by the RN at 2045 reflected that the triage level section was blank. However, the triage level on the Emergency Department Admission Form was identified as a "3".

VS recorded on the untitled form at 2045 included an elevated BP of 142/100. The Vital Details Report reflected that additional VS were taken at 2113 and 2245. There were no other VS documented in the record.

The Outpatient Admission form and the untitled triage and treatment form reflected that the patient was discharged at 2255.

There was no documentation of VS for Patient 5 from 2113, for 1 hour and 32 minutes, until 2245.

4. The ED record of Patient 7 reflected the patient presented to the ED on 04/06/2014 at 2258 with a chief complaint of chest pain. Triage notes recorded on an untitled triage and treatment form by the RN at 2310 identified that the patient was a triage level "3".

VS recorded on the untitled form at 2310 included an increased HR of 106, a BP of 142/92 and a SaO2 of 97%. The Vital Details Report reflected only those VS taken at 2310. There were no other VS documented in the record.

The Outpatient Admission form and the untitled triage and treatment form reflected that the patient was discharged and transferred to another hospital at 0232.

There was no documentation of VS for Patient 7 after 2310, for 3 hours and 12 minutes when the patient was discharged at 0232.

5. The ED record of Patient 8 reflected the patient presented to the ED on 04/08/2014 at 2026 with a chief complaint of chest pain. Triage notes recorded on an untitled triage and treatment form by the RN at 2035 identified that the patient was a triage level "2".

VS recorded on the untitled form at 2035 included an increased HR of 106, an elevated BP of 230/136 and a SaO2 of 96%. The Vital Details Report reflected that additional VS were taken throughout the ED visit and the last set was recorded at 2300. There were no VS documented in the record after that time.

The Lab Summary reflected that blood was drawn for labwork at 2057. The summary reflected that the blood glucose level was reported to be "201.7 [high]" at 2117 where a normal range was 74 to 106. There was no other documentation related to the patient's elevated blood glucose level.

The Outpatient Admission form and the untitled triage and treatment form reflected that the patient was discharged and transferred to another hospital on 04/09/2014 at 0000.

There was no documentation of VS for Patient 8 after 2300, for 1 hour when the patient was discharged at 0000. In addition, there was no evidence of reassessment of the patient's elevated blood glucose level.

6. Additionally, the hospital policy and procedure titled " Capillary Blood Glucose Policy and Procedure", dated "2/2010" was reviewed. It identified that "Capillary blood glucose testing is performed to get an immediate result at that specific time." It consisted of the procedure for performing the test. The procedure did identify "Critical Values for Adults" including "400" for high. However, there were no provisions to address monitoring and assessment of blood glucose levels for diabetic patients or those patient with known elevated levels.

7. During interview with the CNO during the exit conference on 04/25/2014 at 1100 he/she confirmed that there were no additional policies and procedures related to the monitoring of patient blood glucose levels.

In addition, email communication received from the CNO on 04/25/2014 at 1435 indicated that ED staff may re-evaluate acuity during an ED visit which may change the frequency of vital signs, but "That is currently not in our policy".

No additional information or records related to vital sign or blood glucose monitoring for the patients identified above was provided.

Based on documentation in 11 of 12 medical records reviewed (Patients 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11) it was determined that the hospital failed to ensure that all entries on consent forms, ED records, discharge instructions, physician orders, and other documents in the medical records were legible, complete, dated, timed, or authenticated.

Findings include:

1. The medical record of Patient 2 reflected the patient presented to the ED on 05/23/2013. All entries in the record had not been authenticated or dated or timed.
*There was no date and time for either the patient's signature or the witness's signature on the Conditions of Admission form.
* There was no date and time for the patient's signature and no time for the RN's signature on the Patient Care Instructions form.
* The Medication Reconciliation Form had multiple entries, including altered entries, that were not authenticated, dated, and timed.
* Multiple different times were recorded for the patient's discharge from the ED. The Patient Care Instructions form reflected a discharge time of 1824; the RN Progress Notes reflected that the patient was discharged at 1841; the Outpatient Admission form reflected that the discharge time was 1925; and the "embrace CARE" triage and treatment form discharge time had been altered from 1842, which had been crossed out, to a time after 1900 that was partially legible. There was no explanation for the discharge time discrepancies.

2. The medical record of Patient 3 reflected the patient presented to the ED on 05/31/2013. All entries in the record had not been authenticated or dated or timed.
*There was no date and time for either the patient's signature or the witness's signature on the Conditions of Admission form.
* The Emergency Transfer Form lacked the times of the signatures of the RN and the physician.
* The Heparin Protocol Orders form which contained physician orders was not authenticated or dated or timed by the physician.
* The "embrace CARE" triage and treatment form contained numerous entries that had been altered as they had been scribbled out or written over, and were rendered unreadable or illegible. Those included VS, times of treatment or medication administration, and medication dosage.

3. The medical record of Patient 4 reflected the patient presented to the ED on 04/02/2014 and was admitted to the hospital as an inpatient through 04/10/2014. All entries in the record had not been authenticated or dated or timed.
* The Emergency Physician Record lacked the date and time it was completed and authenticated.
* Three pages of Admission Orders lacked the date and time of the physician's orders.
* A Consent-Procedural Treatment form for a "chest tube" was lacking the physician's signature as required by the form.
* The chest tube consent form above lacked the time of the patient's and witness's signatures.
* The Emergency Department Procedural Sedation Record did not include a full date for the procedure as it was recorded as "4/6", and the form was not dated or authenticated by the author.

4. The medical record of Patient 6 reflected the patient presented to the ED on 04/06/2014. All entries in the record had not been authenticated or dated or timed.
*There was no date and time for either the patient's signature or the witness's signature on the Conditions of Admission form.
* The Emergency Transfer Form lacked the dates and times of the signatures of the RN and the physician.
* The Heparin Infusion Protocol form which contained physician orders was not dated or timed by the physician.
* The triage level on the "embrace CARE" triage and treatment form had been altered as it had been scribbled over.
* The Emergency Physician Record lacked the date and time it was completed and authenticated and contained an entry that had been altered as it had been scribbled out.

5. The medical record of Patient 7 reflected the patient presented to the ED on 04/06/2014. All entries in the record had not been authenticated or dated or timed.
* There was no date and time for either the patient's signature or the witness's signature on the Conditions of Admission form.
* The Emergency Transfer Form lacked the times of the signatures of the RN and the physician, and the date of the physician's signature had been altered as it had been written over.
* The Emergency Physician Record lacked the date and time it was completed and authenticated.
* The Medication Reconciliation Form had multiple entries, including altered entries, that were not authenticated, dated, and timed.

6. The medical record of Patient 11 reflected the patient presented to the ED on 02/10/2014 and was admitted to the hospital as an inpatient through 02/12/2014. All entries in the record had not been authenticated or dated or timed.
* The untitled triage and treatment record lacked the ED discharge date and time.
* Entries on the Physician Orders forms for orders dated 02/10/2014 and 02/11/2014 lacked the time of the order or the time was not legible.
* A Consent-Procedural Treatment form for an "EGD" was lacking the date and times of the patient representative's and physician's signatures as required by the form.
* The time on a post-surgery checklist had been altered.
* The EGD/Colonoscopy Procedure Record was not authenticated, dated, and timed by the author of the entries on the form.

7. Similar findings were identified in the records of Patients 1, 5, 8, 9, and 10.

Based on interview and documentation in 4 of 8 medical records reviewed of patients who presented to the ED (Patients 2, 5, 7, and 8), and review of policies and procedures, it was determined that the hospital failed to fully develop and implement policies and procedures to ensure that patient vital signs and blood glucose levels were assessed and monitored throughout the ED visit as indicated by the patient's condition.

Findings include:

1. The hospital policy and procedure titled "Emergency Department Admission, Assessment, Reassessment and Hospital Admission", last dated "[January 2013]", was reviewed. It included the following: "Individualized, goal directed nursing care is provided to all patients, considering each patient's physical...status. The scope and intensity of any further assessments are based on the patient's diagnosis...and the patient's response to any previous care...Triage category be assigned...Reassessment will occur when patients or significant others needs change..."

In regards to VS specifically the policy and procedure required that "Vital signs will be recorded...this includes patients in the waiting room...Every 15 minutes for level 1...Every 15-30 minute level 2-3 (unstable vs)...Every 1 hour for level 3-5 (stable vs)". On the triage scale of "1" to "5", "1" is indicative of patients with the most urgent needs. According to the policy there were no provisions for VS any less frequently than every hour.

2. The ED record of Patient 2 reflected the patient presented to the ED on 05/23/2013 at 1610 with a chief complaint of right thigh pain. Triage notes recorded on the "embrace CARE" triage and treatment form by the RN at 1625 identified that the patient was a triage level "2".

VS recorded on the "embrace CARE" form at that time included an increased HR of 99, a low BP of 74/31 and low SaO2 of 92%. The Clindoc Patient Report reflected that the next set of VS taken was at 1800 but did not include the patient's HR. There were no other VS documented in the record after that.

The Lab Summary reflected that blood was drawn for labwork at 1659. The summary reflected that the blood glucose level was reported to be "536 [high critical]" where a normal range was 74 to 106. A note on the Lab Summary reflected "Called glucose to [staff] in ER, read back. Critical results released 05/23/2013 1749 by [staff]". The "embrace CARE" form reflected that the patient was given 20 units of regular insulin at 1835 for "poorly controlled" diabetes and that the physician ordered a "sliding scale" insulin regimen for the patient to manage at home. There was no other documentation of patient blood glucose levels, either by a blood draw or by a fingerstick CBG, to evaluate the results of the insulin.

The time the patient was discharged from the ED was not clear. The Patient Care Instructions record reflected a discharge time of 1824; the RN Progress Notes reflected that discharge instructions were given and the patient was discharged at 1841; the Outpatient Admission form reflected that the discharge time was 1925; and the "embrace CARE" form discharge time had been altered from 1842, which had been crossed out, to a time after 1900 that was partially legible. There was no explanation for the discharge time discrepancies.

There was no documentation of VS for Patient 2 from 1625, for 1 hour and 35 minutes, until 1800; and after 1800 for 1 hour and 25 minutes when the patient was discharged at 1925, the latest time documented as the discharge time. In addition, there was no evidence that the patient's blood glucose level was reassessed prior to discharge.

3. The ED record of Patient 5 reflected the patient presented to the ED on 03/13/2014 at 2036 with a chief complaint of chest pain. Triage notes recorded on an untitled triage and treatment form by the RN at 2045 reflected that the triage level section was blank. However, the triage level on the Emergency Department Admission Form was identified as a "3".

VS recorded on the untitled form at 2045 included an elevated BP of 142/100. The Vital Details Report reflected that additional VS were taken at 2113 and 2245. There were no other VS documented in the record.

The Outpatient Admission form and the untitled triage and treatment form reflected that the patient was discharged at 2255.

There was no documentation of VS for Patient 5 from 2113, for 1 hour and 32 minutes, until 2245.

4. The ED record of Patient 7 reflected the patient presented to the ED on 04/06/2014 at 2258 with a chief complaint of chest pain. Triage notes recorded on an untitled triage and treatment form by the RN at 2310 identified that the patient was a triage level "3".

VS recorded on the untitled form at 2310 included an increased HR of 106, a BP of 142/92 and a SaO2 of 97%. The Vital Details Report reflected only those VS taken at 2310. There were no other VS documented in the record.

The Outpatient Admission form and the untitled triage and treatment form reflected that the patient was discharged and transferred to another hospital at 0232.

There was no documentation of VS for Patient 7 after 2310, for 3 hours and 12 minutes when the patient was discharged at 0232.

5. The ED record of Patient 8 reflected the patient presented to the ED on 04/08/2014 at 2026 with a chief complaint of chest pain. Triage notes recorded on an untitled triage and treatment form by the RN at 2035 identified that the patient was a triage level "2".

VS recorded on the untitled form at 2035 included an increased HR of 106, an elevated BP of 230/136 and a SaO2 of 96%. The Vital Details Report reflected that additional VS were taken throughout the ED visit and the last set was recorded at 2300. There were no VS documented in the record after that time.

The Lab Summary reflected that blood was drawn for labwork at 2057. The summary reflected that the blood glucose level was reported to be "201.7 [high]" at 2117 where a normal range was 74 to 106. There was no other documentation related to the patient's elevated blood glucose level.

The Outpatient Admission form and the untitled triage and treatment form reflected that the patient was discharged and transferred to another hospital on 04/09/2014 at 0000.

There was no documentation of VS for Patient 8 after 2300, for 1 hour when the patient was discharged at 0000. In addition, there was no evidence of reassessment of the patient's elevated blood glucose level.

6. Additionally, the hospital policy and procedure titled " Capillary Blood Glucose Policy and Procedure", dated "2/2010" was reviewed. It identified that "Capillary blood glucose testing is performed to get an immediate result at that specific time." It consisted of the procedure for performing the test. The procedure did identify "Critical Values for Adults" including "400" for high. However, there were no provisions to address monitoring and assessment of blood glucose levels for diabetic patients or those patient with known elevated levels.

7. During interview with the CNO during the exit conference on 04/25/2014 at 1100 he/she confirmed that there were no additional policies and procedures related to the monitoring of patient blood glucose levels.

In addition, email communication received from the CNO on 04/25/2014 at 1435 indicated that ED staff may re-evaluate acuity during an ED visit which may change the frequency of vital signs, but "That is currently not in our policy".

No additional information or records related to vital sign or blood glucose monitoring for the patients identified above was provided.