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Based on review of one of one Physician Assistant Credential File the Hospital's Governing Body failed to ensure that privileges to perform a medical screening examination for patients presenting to the Hospital's Emergency Department were requested and granted to one of one applicable Physician Assistant.

Findings include:

Review of one of one PA's credential file lacked evidenced that privileges to perform a medical screening examination for patients presenting to the Hospital Emergency Department were requested and granted, despite the medical bylaws indicating that a screening examination may be performed by a PA.

Based on interview and documentation review it was determined that the PA (nor the nursing staff) provided care and or treatment to the Patient's posterior head wound.

Findings include:

1.) The Physician Assistant who evaluated the Patient on 12/21/09 was interviewed in person at 11:15 AM on 1/5/10 and her documentation was reviewed.

2.) The Physician Assistant indicated that the Patient stated she tripped and fell on to the back of her head. The medical screening examination indicated the Patient had an abrasion with ecchymosis in the occipital area. The Physician Assistant said she remembered the Patient and remembered the wound. She said the Patient had a tiny abrasion and remembered 2 to 3 drops of blood on a towel from the abrasion. She said the abrasion was maybe 1 centimeter (cm) to 1.5 cm. However, there was no measurement of the wound documented. The Physician Assistant said she did not clean the Patient's wound , it was superficial and she told Nurse #1 to clean the Patient's head wound.

3.) The Physician Assistant said after Nurse #1 told her about the Patient's dizziness she re-evaluated the Patient. The Physician Assistant said the Patient reported to her that the dizziness was gone, that she was fine. However, the was no assessment of the Patient's dizziness documented.

Based on review of one of one Physician Assistant Credential File the Hospital failed to include evidence that privileges to perform a medical screening examination for patients presenting to the Hospital's Emergency Department were in the PA's credential file.

Findings include:

Review of one of one PA's credential file lacked evidenced that privileges to perform a medical screening examination for patients presenting to the Hospital Emergency Department were requested and granted, despite the medical bylaws indicating that a screening examination may be performed by a PA.

Based on interview and documentation review of one of one applicable ED record the Ed Nurse failed to approprtately evaluate and provide care to the Patient.

Findings include:

1.) The ED nurse, Nurse #1 who triaged and cared for the Patient was interviewed in person on 1/5/10 at 10:00 AM and her 12/21/10 Nursing documentation was reviewed. The assessment indicated the Patient reported her pain level in her posterior scalp was 7.

2.) There was no reassessment of the Patient's wound and there was no documentation for the care and/or comfort provided.

3.) Nurse #1 said the abrasion on the back of the Patient's head was very small, she did not clean the wound or bandage the wound. She acknowledge she did not reassess the Patient's pain after triage and did not document any care or comfort measures provided to the Patient's wound.

4.) Nurse #1 acknowledged she did not document an assessment of the wound, nor document any care or treatment to the wound.

5.) Nurse #1's documentation indicated at 6:23 PM indicated There was no reassessment indicating the dizziness had abated.

Based on interviews and documentation review it was determined the Hospital failed to 1.) ensure an assessment of the wound was documented by the nursing staff, 2.) that the Patient was reassessed after complaining of head pain rated #7 and was reassessed after complaining of dizziness.

Findings include:

See Tag 0395