HospitalInspections.org

Based on interview and document review it was determined the facility staff failed to ensure nine (9) of thirty (30) patients who entered the Emergency Department and were seen by a mid-level provider, had an assessment documented by the mid-level provider. (Patient #1, #3, #4, #11, #12, #21, #22, #24 and #29).

The findings included:

A review of electronic medical records (EMR) was conducted on 06/06/17. For the nine patients, who were seen by mid-level providers in the Rapid Initial Assessment (RIA) area, no evidence was found of an initial assessment by the mid-level provider. This impacted the following patients: Patient #1 (Date of Service (DOS) 02/01/17); Patient #3 (DOS 02/21/17); Patient #4 (DOS 05/28/17); Patient #11 (DOS 05/09/17); Patient #12 (DOS 05/10/17); Patient #21 (DOS 01/02/17); Patient #22 (DOS 02/20/17); Patient #24 (DOS 12/26/16); and Patient #29 (DOS 04/10/17).

The survey team, along with assistance from facility Staff Member #4, Staff Member #6, Staff Member #8 and Staff Member #14, who were navigating the EMR, were unable to locate documentation revealing the initial assessment by the mid-level provider. The survey team requested the policy and procedure related to patient assessments.

An interview was conducted on 06/06/17 at 9:10 a.m. with Staff Member #6 regarding the mid-level provider's assessment documentation. Staff Member #6 stated, "There is no template to document the initial greet. There used to be a template. If the provider that is going to see them (patient) and is going to keep them (patient), then they (provider) will start the assessment; otherwise one is not done until the patient is seen by the medical provider. Within the past 4-5 months I (Staff Member #6) noticed there was no template. The medical director and DAC (IT staff who create the document) were made aware."

Staff Member #13 (Vice President of Quality), was interviewed on 06/07/17 at approximately 8:45 a.m. Staff Member #13 reported he/she became aware of the issue with the assessment documentation template when it disappeared around December (2016) or January (2017). Staff Member #13 stated, "They are currently working on implementing a correction to this missing documentation and it will be corrected." Staff Member #13 reported the facility's policy and procedures did not emphasize the mid-level providers' initial assessment for patients entering into the ED and being placed in the RIA area.

The survey team discussed the concerns regarding mid-level providers failing to document an initial assessment for patients being seen in the ED with Staff Members #4, #6, #8, #13 and #14 during the EMR review. Concerns were again discussed at the end of the day meeting with the Administrative Team.