HospitalInspections.org

16790


Based on staff interview and the review of the facility's Emergency Department (ED) log and medical records, it was determined that the facility failed to maintain a complete and accurate log. Specifically, the disposition of patients seen in the ED was not documented accurately. Additionally, the Labor and Delivery Service failed to maintain a log and disposition of patients encounter. This deficiency was noted in 3 of 32 records reviewed (MR #1, 2 and 3).

Findings include:

The facility Emergency Department (ED) Log for the months April, May, June, and July 2013 were reviewed on 8/7/13.

1. The ED log for the month of June 2013 indicated that the patient, MR #1, was sent to L&D (Labor and Delivery). The ED events section of the patient's record indicated that the patient arrived in the Urgent Care Center on 6/2/13 at 1635 (4:35 pm); she was triaged at 1636 (4:36 pm) and sent to L&D at 1648 (4:48 pm).
The "Hospital Encounter" notes on 6/2/13 at 1946 (7:46 pm), written by a nurse revealed the patient was seen by the physician at 1739 (5:39 pm) for complaint of abdominal cramping. Fetal heart rate was confirmed with external fetal monitor. The physician ordered laboratory tests at 1747 (5:47 pm) and noted the patient should be placed on observation. The nurse note at 1840 (6:40 pm) indicated the patient left the treatment area with her belongings and did not return.
The final disposition of the patient (MR #1) was neither indicated in the ED Log nor maintained in a separate log in the Labor and Delivery. This finding was verified on 8/8/13 at 1:00 pm with the Chief Regulatory Officer.
At interview with the Nurse Manger, Assistant Nurse Manger and a Staff Nurse from the Labor and Delivery Department on 8/8/13 at 11:16 AM, they stated that they do not maintain a log for patients that present to the L&D for assessment.

2. The July 2013 ED Log indicated that MR #2, a 20 month old patient was seen in the Urgent Care Center on 7/5/13 with a chief complaint of breathing problem. The ED log notes the patient was sent to the Operating Room. The review of the patient's record on 8/8/13 at 1:30 pm revealed the patient was admitted.
This finding regarding inaccurate documentation of the patient's (MR #2) disposition was verified by the ED Nurse Manager on 8/8/13 at 2:00 pm.

3. The July 2013 ED Log noted that MR #3, an 88 year old patient, was seen in the Urgent Care Center on 7/27/13 for evaluation of gross hematuria (blood in urine) and was transferred to another facility.
The review of the patient's record on 8/8/13 at 2:30 pm revealed the patient (MR#3) is a resident of a Skilled Nursing Facility and was discharged back to the Nursing Home upon completion of her assessment and treatment in the ED.
This finding regarding inaccurate documentation of the patient (MR #3) disposition as a transfer instead of a discharge was verified by the ED Nurse Manager on 8/8/13 at 2:35 pm.
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Based on staff interview, review of medical records and hospital policy, it was determined that the facility failed to ensure that all patients requiring transfer for further treatment to stabilize their medical conditions are appropriately transferred. This deficiency was noted in one (1) of thirty two (32) medical records reviewed (MR #4).

Findings include:

MR #4 is a 31-year-old male who presented to the ED on 5/18/13 at 0412 (4:12 am) with complaint a Chief Complaint of left shoulder pain. The patient's medical history was significant for Polysubstance Abuse, Alcohol Abuse, and Delirium Tremens. The patient was noted to be agitated and verbally disruptive at triage on 5/18/13 at 0419 (4:19 am). He reported having a seizure and injuring his left shoulder. During assessment of the patient by the ED physician on 5/18/13 at 0545 (5:45 am), he was noted to be unresponsive with small reactive pupils. The patient responded to two doses of Narcan (drug used to counter the effects of opiate overdose).


The psychiatrist's evaluation on 5/18/13 at 1713 (5:13 pm) indicated the patient admitted to Librium overdose but denied suicidal and homicidal ideation. The psychiatrist noted the patient's cognition was grossly intact, insight was limited, judgment was poor, and his impulse control was impaired. The psychiatrist's impression noted status post over dose with intent for self harm. The psychiatrist noted the patient was clearly in need of inpatient psychiatric admission.


On 5/18/13 at 1800 (6:00 pm), the ED physician documented the plan to transfer the patient to a hospital with a psychiatric inpatient unit for evaluation and management of "acute suicidality," once the patient is deemed medically stable for transfer. The patient was noted to be in agreement. The ED Event note written by the nurse on 5/18/13 at 1831 (6:31 pm) indicated that the patient was transferred to another facility by EMS (Emergency Medical Services).


The review of the patient's record on 8/8/13 revealed a lack of documentation of the notification and acceptance by a physician at the receiving hospital prior to the transfer of the patient (MR #4) on 5/18/13 at 1831 (6:31 pm). The medical record did not contain a copy of a signed certification by the sending physician that indicates the benefits of the patient transfer to another facility outweighs the risk. Additionally, there was no documentation that the patient's record was sent to the receiving facility.


During the interview with the ED Medical Director on 8/8/13 at 11:19 AM, he stated the patient referenced in MR #4 received treatment for shoulder pain in the ED on 5/18/13 and during the course of treatment was found to have overdosed on Librium. The patient was assessed by psychiatry who determined the patient needed inpatient admission for evaluation and treatment of "acute suicidality". He informed the surveyor that the sending physician spoke to the receiving hospital but stated the physician did not document the information provided to the receiving facility in the medical record.

The Nursing Director of the Emergency Department, during interview on 8/8/13 at 11:23 am, stated that the facility implemented the Urgent Care Center Transfer policy. This policy includes referral to any of the area hospitals' Emergency Departments that have Inpatient Psychiatry and an ambulance is called to transport the patient. She acknowledged that the Urgent Care Center failed to utilize the Emergency Department's "Inter-Facility Transfer Provider Certification " form, that requires documentation of the following: physician certification of the reason and benefits of transfer; the name of the accepting physician at the receiving hospital, and copies of pertinent medical records are sent with the patient.








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