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Based on documentation review the Hospital failed to ensure that 3 of 17 patients (Patient #3; Patient #4; Patient #5) were properly assessed/reassessed while in the Emergency Department (ED).

Findings included:

Patient #3:
Review of the Hospital's Policy/Procedure titled Assessment/Reassessment of Patients, revised 5/10, indicated that patients in the ED were reassessed a minimum of every 4 hours.

Review of the ED documentation record, dated 10/14/10, indicated that Patient #3 arrived to the ED via auto at approximately 1:20 P.M. The record indicated that Patient #3 was triaged at approximately 1:45 P.M. at which time the initial complaint, vital signs, and height/weight, past medical history, and vital signs were taken. Patient #3 reported a history of lung cancer, chest pain over the past week, and vaginal bleeding with cramping.

Review of the Hospital's Policy/Procedure titled Assessment and Reassessment of Patients indicated that patients in the ED were reassessed a minimum of every 4 hours

Review of the ED documentation record and the ED Physician Record, dated 10/14/10, indicated that Patient #3 was not reassessed until approximately 8:15 to 8:30 P.M.

Review of the ED documentation record, dated 10/14/10, indicated that Patient #3's pain was assessed at approximately 1:45 P.M. Patient #3 reported the chest pain as sharp and rated the pain as 6/10 (0 representing no pain and ten representing the worst possible pain). Patient #3's comfort goal was 0.

Review of the Hospital's Policy/Procedure titled Assessment and Reassessment of Patients indicated that pain reassessment occurs twice per 8 hour shift for patients experiencing pain.

Review of the ED documentation record indicated that the next time Patient #3's pain was reassessed was at approximately 8:25 P.M. The record indicated that Patient #3 was alert and oriented and reported having left chest discomfort that was sharp and intermittent.

Review of the ED documentation and ED Order Sheet, dated 10/14/10 to 10/15/10, indicated that there was no evidence that Patient #3's pain was addressed. Patient #3 was admitted to an inpatient bed at approximately 10:00 A.M. on 10/15/10.

Patient #4:
Review of the ED documentation record, dated 11/18/10, indicated that Patient #4 presented to the ED at approximately 6:10 P.M. after a fall at home. Patient #4 was alert and able to respond to questions and reported experiencing throbbing left arm pain. Patient #4 rated the level of pain as 1/10 without movement and 9/10 with movement.

Review of the ED documentation record, ED Order Sheet, and ED Physician Record, dated 11/18/10, indicated that there was documented re-assessment of Patient #4's level of pain and there were no interventions provided until approximately 1:10 A.M. on 11/19/10 when Patient #4 was administered Tylenol 650 milligrams (mg) for a headache. There was no documentation of the effectiveness of the Tylenol or pain reassessment.

Patient #5:
Review of the ED documentation record, dated 11/19/10, indicated that Patient #5 reported having pain in the sternum and epigastric area rated as 9/10 and was administered intravenous Morphine (narcotic analgesic) for pain at approximately 2:45 A.M.

Review of the ED documentation record, dated 11/19/10, indicated that Patient #5 was transferred to an inpatient bed at approximately 10:30 A.M. There was no documented evidence that Patient #5's pain was reassessed from the time the Morphine was administered until Patient #4's transfer.

Based on documentation review the Hospital failed to ensure that medical record entries were legible, dated and timed for 2 of 17 patients (Patient #10 and Patient #17).

Findings included:

Patient #10:
The ED documentation record, dated 10/31/10, indicated that at approximately 5:50 P.M. the Admitting Physician contacted the ED nurse and issued a telephone order for a nasogastric tube to be inserted and attached to wall suction.

Review of the Physician Order Sheet, dated 10/31/10, indicated that the order was documented but was not timed.

Patient #17:
Review of the Initial Emergency Order Sheet, dated 11/10/10, indicated that orders were written for nebulizer treatments times 3, Solumedrol, Rocephin, and Azithromycin.

The Initial Emergency Order Sheet was a preprinted form with areas to document the the time(s) each medication and respiratory orders were written. At the bottom of the Sheet there was an area for the physician to sign and document the date/time

Review of the Emergency Order Sheet indicated that the medication orders were not timed and the physician's signature, although dated, was not timed.

Based on documentation review the Hospital failed to ensure that a telephone/verbal order was authenticated by the physician within 48 hours for 1 of 17 patients (Patient #10).

Findings included:

The ED documentation record, dated 10/31/10, indicated that at approximately 5:50 P.M. the Admitting Physician contacted the ED nurse and issued a telephone order for a nasogastric tube to be inserted and attached to wall suction.

Review of the Physician Order Sheet, dated 10/31/10, indicated that the telephone/verbal order was not authenticated by the physician.

Based on documentation review, the Hospital failed to ensure that medical record documentation was completed/accurate for 6 of 17 patients (Patient #1; Patient #3; Patient #4; Patient #6; Patient #12, and Patient #17)

Findings included:

Patient #1:
Review of the Emergency Physician Record, dated 10/31/10, indicated that the sections regarding disposition of the patient, the condition of the patient, the name of the physician to whom care was transferred, and the time care was transferred was not completed.

Patient #3:
Review of the Emergency Physician Record, dated 10/14/10, indicated that the sections regarding the clinical impression, disposition of the patient, and the condition of the patient were not completed.

Patient #4:
Observation during a tour of the Emergency Department (ED, conducted on 11/19/10 at approximately 8:35 A.M. indicated that Patient #4 was transferred to an inpatient bed during the tour.

Review of the ED documentation record, dated 11/19/10, indicated that the time Patient #4 was transferred out of the ED as well as the destination was not documented in the medical record.

Patient #6:
Review of the Emergency Physician Record, dated 9/27/10, indicated that the ED physician did not document the time Patient #6 was examined.

Review of the ED documentation record, dated 9/28/10, indicated that the time Patient #6 was transferred out of the ED as well as the destination was not documented in the medical record.

Review of the ED documentation record, dated 9/28/10, indicated that Patient #6 was admitted to the Hospital with appendicitis. Although Patient #6 was admitted to the Hospital, discharge instructions were provided which did not match Patient #6's profile. Instructions included follow-up with the pediatrician at the end of the week (Patient #6 was 30+ years-old) and take Motrin for pain.

Patient #12:
Review of the Laboratory Report, dated 9/29/10, indicated that a d-Dimer test was performed at 8:33 A.M. The results were 3630 (normal range is 0-399; elevations indicative of a pulmonary embolism or thrombosis).

Review of the Initial Emergency Order Sheet, 9/29/10, indicated that there was no documented order for the d-Dimer to be performed.

Review of the Emergency Department documentation, dated 9/29/10, indicated that there was no documentation to indicate that the abnormal d-Dimer result was reported to the ED physician who was on duty.

The Hospitalist was interviewed on 12/3/10 and 12/7/10 and the Risk Manager was interviewed on 12/7/10.

The Hospitalist said the d-Dimer was ordered and performed in the afternoon when Patient #12 had an increased need for oxygen.

The Risk Manager said a tracking of the d-Dimer was performed and determined that the d-Dimer was performed at approximately 2:58 P.M. The Risk Manager said the d-Dimer was an add-on, meaning it was performed using the blood collected for the morning blood tests and was incorrectly documented as being performed at 8:33 A.M.


Patient #17:
Review of the Emergency Physician Record, dated 11/10/10, indicated that it was unclear as to when the ED physician initially examined Patient #17.

Review of the ED documentation record, dated 11/10/10, indicated that Patient #17 was seen by the ED physician at approximately 10:28 A.M.

Review of the Emergency Physician Record, the first page, indicated that Patient #17 was initially examined by the ED Physician however; the time was not documented. The second page of the Record indicated that Patient #17 was re-examined. The ED physician signed the bottom of page 2 and timed the signature as 11:11 A.M.

Based on observation and interview the Hospital failed to ensure that all areas of the Emergency Department's (ED) Waiting Area was visible to the triage station.

Findings included:

A tour of the ED was conducted on 11/19/10 at 8:25 A.M. with the ED Nurse Manager present. The Nurse Manager reported that the triage nurse was responsible for patients in the Waiting Areas and that paramedics, hired as patient ambassadors, were also assigned to check on the Waiting Areas during rounding.

Observation during the tour revealed the following: the triage room was located across from the walk-in entrance to the ED. To the right was a small Waiting Area located just outside Triage and was observable to triage. The door to triage could be opened to check on patients seated there and the area was visible on the video surveillance monitor located inside Triage. To the left of Triage was the Security Booth and to the left of the Security Booth was the large Waiting Area. All areas of the large Waiting Area were visible to triage either through the window of Triage or on the video surveillance monitor with the exception of an alcove. The alcove was located directly to the left of the security booth. Observation from Triage and of the video surveillance monitor indicated that anyone seated in that alcove could not be viewed unless someone physically walked over to look into the alcove.

At the time of the tour there was only 1 person in the alcove that when approached, identified self as a visitor.