HospitalInspections.org

Based on policy review, medical record review and interview, the hospital's failed to ensure the emergency room nursing staff did an assessment to provided a history of procedures for patients in order to prevent unnecessary procedures.

The findings include:

Medical record review revealed Patient #1 was admitted to the Emergency Room (ER) on 7/26/2021 with diagnosis of Chest Pain and Nausea.

Review of the Emergency Room (ER) statement stated Emergency Services would provided an initial assessment by qualified personnel.

Review of the physician orders revealed an order for a pregnancy test.

Review of the final report for the ER revealed no documented procedure history and the patient was alert.

During an interview on 10/26/2021 with the Quality Coordinator (QC) she would be finding out from the physician why the pregnancy test was ordered.

In an e-mail correspondence on 10/27/2021 the QC was unable to talk to the physician to find out why he ordered the pregnancy test and would be getting back with this surveyor.

In an e-mail correspondence on 10/29/2021 with the Chief Quality Officer (CQO) the CQO stated that she was unable to get a statement from the Physician Assistant #1 and that the Medical Director from the ER had review the record and stated that on the review of the chart it was ordered for safety and because a Chest x-ray had been ordered. He further stated that there was no documentation on file for any previous sterilization procedures or surgeries.

In an e-mail correspondence on 11/1/2021 this surveyor asked if the ER should do an assessment that covered procedures and where could you find the question documented that asked could you be pregnancy. This surveyor was told I had received that information in a statement from the Medical Director on the previous e-mail.

Based on policy review, medical record review and interview, the emergency room (ER) nursing services failed to ensure that all patient's needs were met by ongoing assessments of patient's needs and took measures to ensure procedural assessment's were completed and up to date for 1 (Patient #1) of 3 sampled patients.

The findings include:

Medical record review revealed Patient #1 was admitted to the Emergency Room (ER) on 7/26/2021 with a chief complaint of midsternal chest pain with nausea.

Review of the undated hospital's policy statement revealed, "...Patients who present to Emergency Services will be provided an appropriate initial assessment by qualified personnel as defined by Triage Assessment of Patients By Emergency Severity Index (ESI)..."

Review of the physician orders for 7/26/2021 revealed an order for a pregnancy test.

Review of the final report for the ER on 7/26/2021 revealed, "...Procedure history...No active procedure history items have been selected or recorded...Neurological...Alert...Major Test and Procedures...no procedures documented..Laboratory Orders...hcG Qual [pregnancy test]..."

During an interview on 10/26/2021 at 1:30 PM, with Robin Reid Quality Coordinator (QC) the QC stated the physician that had ordered the pregnancy test would be back tomorrow 10/27/2021 on shift in the ER at 3:00 PM, and she would have him review the chart and find out why he ordered the pregnancy test.

In an e-mail correspondence on 10/27/2021 at 3:34 PM, with the QC, the QC stated, "...He (physician) apparently switched shifts with someone today. I (QC) will email you his rationale for the pregnancy test tomorrow..."

In an e-mail correspondence on 10/29/2021 at 12:58 PM, with the Chief Quality Officer (CQO) the CQO stated, "...We just found out that the Physician Assistant #1 (PA #1) will be out for an extended length of stay. I did have the Medical Director from the ER to review the record and below is his response...Based on the review of the chart, I think this was ordered from a safety perspective. Specifically, a pregnancy status would be needed if this patient received a chest x-ray or received any cardio specific medications (i.e. aspirin, nitroglycerin, etc.). This patient had no documentation of having any sterilization procedures and no history of post-menopause...Also, there was no complaint or grievance that was filed on 7/26 or 9/13/2021. There is no documentation of any previous surgeries or procedures done in the past for either encounter..."

In an e-mail correspondence on 11/1/2021 at 9:01 AM, this surveyor asked the CQO the following questions: "...Should your ER assessment in the ER cover previous surgeries and where is the question documented that ask you if you are pregnant, should that also be in the [patient] assessment...." a return e-mail correspondence on 11/1/2021 at 11:08 AM, stated, "...I (CQO) sent you an explanation from the ED Medical Director on Friday due to the fact that the PA that was involved in the care will be out for an extended period of time. I reviewed the patient record again and there is no documentation regarding pregnancy on either visit. Her encounters were during the time of our surge of COVID-19 patients..."