HospitalInspections.org

Based on document review, policy review, and staff interview the facility failed to ensure every patient who presented to the emergency room seeking treatment was documented on the central log in the emergency room.

Findings were:

Emergency room central log for June 1, 2019-September 9, 2019 was reviewed. A central log is kept of patients presenting for treatment in the facility. Review of September 1, 2019 has no entry for Patient #1 presenting to the facility seeking treatment of a medical condition.

Facility policy titled "Triage of Patients Presenting to the Emergency Department" states in part:
"Policy:
* All patients presenting to the emergency room will be triaged. Triage determines the order in which patients will be seen. Triage is not equivalent to a medical screening exam. It does not determine the presence or absence of an emergency medical condition.
Desired Patient Outcomes: All emergency patients will receive prompt emergency care according to their urgency level."

Facility policy titled "Admission/Discharge-Emergency Department" states in part:
"Purpose: Establish criteria in which appropriate information is received and given to all patients entering and leaving the Emergency Department.
Policy:
* All patients will be evaluated by the triage nurse prior to Emergency Department (ED) Registration.
* The appropriate demographic information will be obtained by the Emergency Department Clerk during the hours provided, otherwise the information is obtained by a member of the ED staff.
* Emergency Department patients must sign a "Consent for Treatment" form. If the patient is unable to sign, the legal representative may sign. If no one is available to sign the consent, document the reason the patient is unable to sign, write "Unable to Sign" in the appropriate space and provide your signature."

In an interview with staff #7 she stated patient #1 presented to the emergency room window with complaint of a snake bite to his thumb. She stated the nurse was standing behind her and stated to the patient they could see him but could not treat him as they had used the anti-venin earlier on another patient and he would have to be treated at another hospital. She stated he walked out of the emergency room and she followed him outside. She stated a woman walked up and she told her the same thing. She stated the patient and the woman got mad and wanted to know why we could not treat him. She stated the nurse was standing there with her and he told the woman they had a snake bite earlier and had used the antivenin on that patient. She stated the patient never gave her any information and the woman and the patient left the facility. She stated she did not log the encounter in to the hospital central log for the emergency room.

In an interview with staff #5 he stated the patient had walked up to the window holding his hand and stated he had been bit by a snake. He stated he offered to see the patient but told him they did not have the medication to treat him as they had used it earlier on another patient. He stated the patient said if you are not going to treat me I am leaving. He stated the woman who came with the patient asked where the nearest hospital was where the patient could be treated.

Based on document review, policy review, and staff interview the facility failed to ensure every patient who presented to the emergency room seeking treatment was provided with a medical screening.

Findings were:


Facility policy titled "Triage of Patients Presenting to the Emergency Department" states in part:
"Policy:
* All patients presenting to the emergency room will be triaged. Triage determines the order in which patients will be seen. Triage is not equivalent to a medical screening exam. It does not determine the presence or absence of an emergency medical condition.
Desired Patient Outcomes: All emergency patients will receive prompt emergency care according to their urgency level."

Facility policy titled "Admission/Discharge-Emergency Department" states in part:
"Purpose: Establish criteria in which appropriate information is received and given to all patients entering and leaving the Emergency Department.
Policy:
* All patients will be evaluated by the triage nurse prior to Emergency Department (ED) Registration.
* The appropriate demographic information will be obtained by the Emergency Department Clerk during the hours provided, otherwise the information is obtained by a member of the ED staff.
* Emergency Department patients must sign a "Consent for Treatment" form. If the patient is unable to sign, the legal representative may sign. If no one is available to sign the consent, document the reason the patient is unable to sign, write "Unable to Sign" in the appropriate space and provide your signature."

In an interview with staff #7 she stated patient #1 presented to the emergency room window with complaint of a snake bite to his thumb. She stated the nurse was standing behind her and stated to the patient they could see him but could not treat him as they had used the anti-venin earlier on another patient and he would have to be treated at another hospital. She stated he walked out of the emergency room and she followed him outside. She stated a woman walked up and she told her the same thing. She stated the patient and the woman got mad and wanted to know why we could not treat him. She stated the nurse was standing there with her and he told the woman they had a snake bite earlier and had used the antivenin on that patient. She stated the patient never gave her any information and the woman and the patient left the facility.

In an interview with staff #5 he stated the patient had walked up to the window holding his hand and stated he had been bit by a snake. He stated he offered to see the patient but told him they did not have the medication to treat him as they had used it earlier on another patient. He stated the patient said if you are not going to treat me I am leaving. He stated the woman who came with the patient asked where the nearest hospital was where the patient could be treated. He further stated he did not tell the woman or the man that they could evaluate him and transfer him to a hospital that could treat him if necessary. He stated he did not tell the physician in the emergency room about the patient presenting with the snake bite until after the patient had left the hospital.

In an interview with staff #2 she stated every person who presents to the emergency room is to be triaged and provided with a medical screening. She stated the nurse should not tell the patient they could not treat the patient and they would have to go to a different hospital for treatment.