HospitalInspections.org

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Based on document review and interview, the facility failed to ensure that Medical Records correctly documented the Physicians' initial encounter with patients in two (2) of the three (3) Level 2 Triage Medical Records reviewed (Patients #9 and #11).

Findings:

Patient #9 was seen in the Emergency Department on 12/17/14 for chest pain. The Medical Record revealed that the patient arrived at 8:41AM. An EKG (Electrocardiogram) was performed at 8:44AM, and orders for lab work and additional tests were entered by the Physician (MD) at 9:19AM.

The History and Physical was not documented until 11:11AM on 12/17/14. The first documentation that the patient was seen by the Physician was noted on the face sheet as "Provider in room with patient" at 9:45AM.

Patient #11 was seen in the Emergency Department on 12/18/14 for chest pain and weakness. The Medical Record revealed that the patient arrived at 3:38AM. An EKG was performed at 3:44AM, and orders for lab work and additional tests were entered by the MD at 3:51AM.

The History and Physical were not documented until 4:44AM on 12/18/14. The first documentation that the patient was seen by the Physician was noted on the face sheet as "Provider in room with patient" at 4:44AM.

Interview with Staff #4 on 12/19/14 at 11:00AM revealed that the Medical Screening Exam (MSE) in this facility is done with patients being seen in "parallel, not in series". For example, the Physician would go into a room and assess the EKG; if normal, the Physician would order appropriate labs and seeing that the patient is stable, would proceed to the next patient. The staff member referred to this technique as "thin slicing". The staff member further stated that this way was more efficient to ensure there is no delay in care or treatment. The documentation cannot always be done immediately after seeing a patient because it could result in a delay in getting to the next patient.

Review of the facility's Policy titled "Triage - Initial Patient Assessment" on Page 4 under "The ED Physician will" document that Level 2 Triage patients will be seen "As soon as possible within 15-30 (fifteen to thirty) minutes of arrival".

The documentation reviewed does not support this Policy. The facility lacks a mechanism or procedure to ensure documentation of the Physicians' encounters with a patient that reflects an accurately recorded timeline of the patient's care in the Medical Record.
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Based on observation, documentation review and interview, the facility failed to ensure that: a) Infection Control Practices were used during glucose monitoring, and following the completion of the procedure, in one (1) of one (1) patient observations (Patient #10), and b) a clean and safe environment was maintained in two (2) of five (5) room observations.

Findings:

a) Patient #10 was admitted to the Emergency Department (ED) on 12/19/14 with a diagnosis of Chest Pain with Severe Shortness of Breath. The patient has a history of Myocardial Infarction, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Acute Kidney Failure and Diabetes.

On 12/19/14 at 11:55 AM Staff #3 was observed obtaining a blood sugar via glucometer.

During the observation, it was noted that the staff failed to wash their hands prior to the procedure before donning gloves. Staff #3 then placed the tote onto the patient's bedside table.

This was observed in the presence of Staff #2 at the time of the glucometer testing, who acknowledged that the Nurse did not wash their hands.

Review of the facility's Policy titled "Blood Glucose Monitoring" dated 09/12 under "Procedure" revealed that staff should "Wash hands upon entering the room and use gloves as per BMHMC (Brookhaven Memorial Hospital Medical Center) Infection Control Guidelines."

During the glucose monitoring for Patient #10, it was noted that the glucometer machine was placed onto the patient's bedside table during the procedure, and then the dirty machine was placed back into the tote, after the procedure, without sanitizing the machine or the tote.

Staff #3 then proceeded to return the dirty tote to the Storage Area in the Med Room without sanitizing the tote. Staff #3 was stopped before entering the Med Room.

Staff #3 was then observed wiping the outside of the tote with a Sani-Wipe and then wiping the glucometer machine with the same wipe and placing it back into the tote.

Staff #3 failed to wipe the inside of the tote or change Sani-Wipes before wiping the machine and returning the glucometer to the tote.

This was observed in the presence of Staff #2 after glucometer testing was completed, who acknowledged that the glucometer was not wiped before being placed back into the tote.

Review of the facility's Policy titled "Blood Glucose Monitoring" dated 09/12 under Section "B", "Preventative Maintenance", "Frequency" states "1) Clean meter when contaminated and after every patient glucose test."

The Policy lacks instruction regarding the cleaning of the tote.

b) On 12/18/14 at 11:50AM, during a tour of the ED, it was observed that the Sharps Container in Room "Acute 4" was overfilled. Staff were attending to a patient in the room at the time of observation.

On 12/18/14 at 11:55AM, during a tour of the ED, it was observed that the Sharps Container in Room "AMI 2" (Cardiac Room) was full. The room was empty, clean, and ready for the next patient at the time of observation.

Interview with Staff #1 at the time of discovery revealed "There is a contracted company that comes and picks up the Sharps Containers on Thursdays." When asked what happens if the containers become full prior to Thursdays, the staff member replied "We can call Environmental Services to change them, they have a key."

Since the date of the tour was a Thursday, Staff #1 acknowledged that to ensure the safety of the staff, since the containers were completely full, they should have been changed by the facility instead of waiting for the contracted company.