HospitalInspections.org

Based on staff and physician interviews, clinical record and administrative document reviews, the hospital failed to ensure the clinical record contained documentation that was accurate and complete as pertained to the past medical history, initial assessments, treatments, interventions and reevaluations for 1 of 1 Patients, during an Emergency Department visit. This failure had the potential to cause harm to Patient 1 and prevent the highest practicable level of functioning and quality of life.

Findings:

On 10/11/11 at 2:30 p.m., during a concurrent interview and clinical record review the EDM (Emergency Department Manager), stated, the hospital form titled "Triage summary (an initial evaluation form outlining what caused the accident, injuries, complaints and concerns provided by the paramedics prior to arrival at the hospital) was incomplete. The EDM further stated, the record did not contain documentation of the past medical history, social history, identification and description of the wounds, abrasions (skin scrapes) or lacerations (deep cuts into the skin), Patient 1 had upon arrival to the ED. The EDM further stated, the clinical records were required to be accurate and complete. The ED record did not contain any evidence of a call to Patient 1 by a LN (licensed nurse) for follow up of foreign bodies present on the left hand x ray, as requested by MD 3.

The EDM further stated there were cervical spine precautions (a cervical collar was very stiff and applied around the neck to prevent movement) and a backboard (hard, patient length, plastic or wood board used to keep the patient from moving their spine until a decision had been made that the neck and spine had not been injured) initiated by the emergency response team. The triage clinical record, written by LN 1 had documented the c-collar and backboard had been in place at the time Patient 1 at the ED. There was no documentation in the clinical record of the time or who removed the collar and backboard and there was no documentation of who ordered the discontinuance of the Cervical and spinal precautions.

On 10/11/11 at 3:00 p.m., the Policy and Procedure titled, "Emergency Department Standard of Care-Lacerations and/or Abrasions...Policy: 2. ...Documentation shall include, but not be limited to:...description and location of injury... c)...patient arriving in the Emergency Department with lacerations and/or abrasions.

On 10/14/11 the current facility policy and procedure dated 6/1/00, titled,"Cervical Traction or C-Spine Immobilization ...1. Indication for Manual Cervical traction: a) suspected or known c-spine (cervical spine) injury:... traffic collision...f) documentation shall include, but is not limited to when and who ordered removal of C-Spine precautions...."