HospitalInspections.org

Based on record review and staff interviews, the hospital failed to ensure patient care was supervised, evaluated and monitored by a registered nurse in one (1) of twenty (20) charts reviewed. This has the potential to affect all patients by resulting in the failure to identify a change or deterioration in patient status resulting in poor patient outcomes.

Findings include:

1. Review of the medical record of patient #1 revealed the patient presented to the Emergency Department (ED) on 4/23/12 at 1735 with complaints of a fall one week ago, pain to both arms, pain to left chest wall, and "sent from MD office for low hgb". The patient was brought to the ED by emergency transport. After triage the patient remained on a stretcher in the ED hallway until 1940 when she was placed in an ED cubicle. She was assigned a Registered Nurse (RN). The patient remained in the ED cubicle for three (3) hours and left the ED without being seen at 2240. Total length of stay in the ED was approximately five (5) hours.

The record reflects that the patient was not seen by a RN after her initial triage. The patient was not placed on any type of monitoring system. The patient's vital signs were not obtained again after triage.

2. An interview was conducted with the RN assigned to patient #1 on 5/15/12 at 0950. He stated that his first communication with this patient, and his only interaction, was when he saw the patient's family member "looking for something". The RN stated that the patient's family member asked for a wheelchair and stated that they were not receiving care and were leaving.