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Based on record review, staff interview and documentation provided by the hospital, the hospital failed to ensure that one of of 37 sampled patients (patient #3) received appropriate services to re-insert a gastric tube upon arrival at the emergency department. The hospital's census was 80 patients.

Findings include:

The review of the clinical record of patient #3 on 5/27/2010, indicated the patient arrived at the emergency department of the hospital at 1:00PM on 04/08/2010, with his/her gastrostomy tube out. The record did not have documentation that treatment was rendered to the patient by the emergency department staff. There was no documentation in the emergency department reports to indicate the triage nurse evaluated the patient. Interview of emergency department staff (Staff D, G, H, I and J) stated the patient must have left without treatment.

Further questioning of the emergency department staff revealed the patient was probably sent to the GI clinic to have the tube placed since the patient had been a patient of the GI clinic in the last year. The emergency room has a policy and procedure entitled the "MicKey G-tube Flow Chart" dated 12/2007 which reflects if the patient has been seen in the GI clinic in the last year and if the GI clinic is open, the patient would be sent to the GI clinic. Staff stated that they started this practice to prevent the patient from having to pay for an emergency visit.

The GI clinic staff (Staff F, K, and L) was interviewed 5/26/10, in the morning hours, regarding the arrival of patient #3 on the GI unit on 04/08/10. The GI staff stated they could not remember if the patient came to the GI unit; however if the patient did come to the GI unit and the patient's doctor was not there, the patient would be sent back to the emergency room or advised to see their physician. It was ascertained the patient had been seen in the GI clinic in the last year, however the patient's physician had left the clinic's practice in June of 2009 and transferred to Columbus Children's Hospital's GI clinic. The emergency room staff stated they would not have known that the physician had left the GI clinic prior to sending patient #3 to the GI clinic for treatment.

Further investigation revealed that there was an emergency room policy entitled "Emergency Department Policy for Patients who present with accidentally removed/leaking MicKey Gastrostomy Tubes". The policy states "When a gastrostomy tube is accidentally removed, it is essential to replace that tube as soon as possible in order to maintain patency of the stoma and adequate enteral nutrition; as well as to provide limited interruption of necessary medications. In addition, it is necessary to promptly treat any leakage of enteral feeding products, medications, and gastric secretions around the stoma in order to prevent skin breakdown". The purpose of the policy was to provide guidelines for consistent and appropriate care for the patient who presents to the Emergency Department with an accidentally removed and/or leaking MicKey G-Tube. The guidelines were to assure the patient would maintain enteral access for nutritional/medication needs and maintain proper skin integrity around the stoma. The triage nurse was to initiate the process and follow the flow chart established.

The emergency room triage level when a G-Tube is out is a level 2 which is considered a high risk patient and requires emergent interventions.

The emergency room triage nurse did not follow up and/or call a report to the GI clinic nurse or physician regarding the care and treatment of the patient sent to the GI clinic. The system the hospital has in place does not provide for collaborations with the physicians and/or nurses in the GI clinic. Communication failures could result in inadequate care for patients presenting to the emergency room/department.

The hospital administrative staff (A, B, C, and E) confirmed on 05/27/2010 in the morning hours the above incident was a problem which they were unaware that had occurred. The patient should have been treated in the emergency department. There is a GI physician on-call 24/7. The GI clinic is staffed by physicians for scheduled patients. The clinic was and is not set up for walk-ins. The hospital did not ensure that patient #3 was treated when the patient presented to the emergency room/department. Staff J on 05/27/10 at 2:00 PM stated " this issue would not have happened if the patient had presented to the ED after clinic hours and we now know we have a problem."