HospitalInspections.org

Based on record review and interview the facility failed to provide stabilizing treatment of a patient needing acute dialysis. Citing 1 (# 1 A) out of 20 patient record reviewed. This deficient practice caused harm to patient # 1 A and had the potential to cause harm to all patients receiving emergency care at the facility.

Findings:


Review of emergency department ( ED) medical record of patient # 1 A on 01/15/2013, revealed that this 48 year old dialysis patient was brought to the ED at 05:28 a.m. 12/03/2012 by ambulance from the parking lot of a local dialysis unit. The vital signs were recorded on arrival as B/P 152/74, pulse 110, respirations 19; O2 sat on 5% simple mask 97%, and temp 98. The weight was recorded at 85 kg (R)and the height was documented as 4 ft. 11 in. The repeat vital signs were recorded at 06:41 a.m. as B/P 149/85, pulse 98, respirations 20, O2 sat 96% (the O2 sat does not indicate how the oxygen was being given or if it was recorded with or without O2) and temp 97.6. The record revealed that the patient was assessed by nurse (# 4) who documented at 06:35 that the patient was in no apparent distress, resting quietly and was awaiting re-evaluation by ED physician. Physician (#6) documented initial assessment at 06:29, respiratory positive for shortness of breath. Heart rate was tachycardia, rhythm regular. He further documented that the medical screen was done at 05:26 a.m.. He ordered x-rays and BMP, CBC with Auto Diff. He documented his chest x-ray interpretation was early edema. In addition, he documented on 12/03/2012 at 06:35 discharge to home, condition stable, with discharge instructions for pulmonary edema. The record revealed that the patient was discharged by private car. There was no documentation to indicate the patient received stabilizing treatment for her acute condition or that arrangement for transfer to a higher level of care was considered since this ED did not have dialysis capabilities.

Review of emergency department (ED) medical record of patient # 1 A on 01/15/2013 revealed that this 48 year old dialysis patient was brought to the ED a second time on 12/03/2012 at 08:56 a.m. The record revealed that she was brought in by ambulance in full cardiac arrest from a local dialysis facility. Resuscitation efforts were done by the hospital team without success. The patient was administered Epinephrine 1 mg (a drug to stimulate the heart) times four doses in the emergency department. The time of death was recorded at 09:04 a.m..

During an interview conducted on 01/15/2013 at 2:00 p.m., staff # 1 confirmed that there was no evidence the facility provided acute dialysis treatment to this dialysis patient with shortness of breath and early pulmonary edema. She stated that this facility transfers patients to a Tyler hospital for dialysis but was not done for this patient.

An interview with with the Dialysis Facility Charge Nurse by telephone on 01/15/2013 at 3:00 p.m., revealed that the patient presented to the dialysis unit around 7:00 a.m. on 12/03/2013. She stated that the patient was short of breath and was 7 kg above her dry weight of 85 kg. She stated she attempted to dialyze the patient but her shortness of breath increased and she called the ambulance for transport back to the emergency room.

Based on records review and interviews, the facility failed to appropriately transfer a patient with an emergency medical condition and required acute dialysis. Citing 1 (# 1 A) out of 20 patient record reviewed. This deficient practice caused harm to patient # 1 A and had the potential to cause harm to all patients receiving emergency care at the facility.

Findings:


Based on record review and interview the facility failed to appropriately transfer a patient with an emergency medical condition and required acute dialysis. Citing 1 (# 1 A) out of 20 patient record reviewed. This deficient practice caused harm to patient # 1 A and had the potential to cause harm to all patients receiving emergency care at the facility.

Findings:


Review of emergency department ( ED) medical record of patient # 1 A on 01/15/2013, revealed that this 48 year old dialysis patient was brought to the ED at 05:28 a.m. 12/03/2012 by ambulance from the parking lot of a local dialysis unit. The vital signs were recorded on arrival as B/P 152/74, pulse 110, respirations 19; O2 sat on 5% simple mask 97%, and temp 98. The weight was recorded at 85 kg (R)and the height was documented as 4 ft. 11 in. The repeat vital signs were recorded at 06:41 a.m. as B/P 149/85, pulse 98, respirations 20, O2 sat 96% (the O2 sat does not indicate how the oxygen was being given or if it was recorded with or without O2) and temp 97.6. The record revealed that the patient was assessed by nurse (# 4) who documented at 06:35 that the patient was in no apparent distress, resting quietly and was awaiting re-evaluation by ED physician. Physician (#6) documented initial assessment at 06:29, respiratory positive for shortness of breath. Heart rate was tachycardia, rhythm regular. He further documented that the medical screen was done at 05:26 a.m.. He ordered x-rays and BMP, CBC with Auto Diff. He documented his chest x-ray interpretation was early edema. The record revealed that the patient was discharged home by private car. There was no documentation to indicate the patient received stabilizing treatment for her acute condition. There was no evidence that this facility transfered the patient to another facility so the patient can be provided with acute dialysis to stabilize her condition.

Review of emergency department (ED) medical record of patient # 1 A on 01/15/2013 revealed that this 48 year old dialysis patient was brought to the ED a second time on 12/03/2012 at 08:56 a.m. The record revealed that she was brought in by ambulance in full cardiac arrest from a local dialysis facility. Resuscitation efforts were done by the hospital team without success. The patient was administered Epinephrine 1 mg (a drug to stimulate the heart) times four doses in the emergency department. The time of death was recorded at 09:04 a.m..

During an interview conducted on 01/15/2013 at 2:00 p.m., staff # 1 confirmed that there was no evidence the facility provided acute dialysis treatment to this dialysis patient with shortness of breath and early pulmonary edema. She stated that this facility transfers patients to a Tyler hospital for dialysis but was not done for this patient.

An interview with with the Dialysis Facility Charge Nurse by telephone on 01/15/2013 at 3:00 p.m., revealed that the patient presented to the dialysis unit around 7:00 a.m. on 12/03/2013. She stated that the patient was short of breath and was 7 kg above her dry weight of 85 kg. She stated she attempted to dialyze the patient but her shortness of breath increased and she called the ambulance for transport back to the emergency room.