HospitalInspections.org

Based on reviews of 22 medical records of patients seen in the Emergency Department (ED) between 1/1/2016 and 3/15/2016 it was determined that the hospital staff failed to document the risks and benefits to patients who transferred to another acute care facility on the "Acute Care Transfer Form" for 3 of 12 patients (#7, 12 and 13) transferred.

An interview with the Director of Nursing for the ED on 3/15/2016 revealed that the physicians verbally discuss the risks and benefits of the necessary transfer to all patients or the patient's family members then document those risks as discussed on the "Acute Care Transfer Form." The medical record of Patient #7 was reviewed with the Director of Nursing for the ED and s/he confirmed that the risks and benefits of the transfer had not been documented for this patient.

Failure of the physician or hospital staff to document all required information on the "Acute Care Transfer Form" has the potential for patients not receiving sufficient information that is subject of the entry to permit the medical record to satisfy the completeness standard.

Based on observations in the Emergency Department (ED) and an interview with the Director of Nursing of ED on 3/15/2016 it was determined that the hospital staff failed to complete the required daily emergency equipment check as required by hospital policy.

Observation in the ED on 3/15/2016 revealed that the "Adult Code Cart/Emergency Equipment Checklist" was not completed for the Code Cart in ED room #5 from 3/12/2016 to 3/15/2016 (at the time of observation). This finding was confirmed with the Director of Nursing for the ED. The Director of Nursing for the ED stated that, per hospital policy, staff are required to check all code carts daily (including medications in date, supplies and equipment intact and defibrillator plugged in and charged) and then to document this on the "Adult Code Cart/Emergency Equipment Checklist."

Failure of staff to ensure that all emergency equipment is stocked and functioning properly places patients at risk for delay in life saving treatment and/or interventions.