HospitalInspections.org

Based on review of the emergency department (ED) logs and ED medical record and treatment documentation, and staff interviews, Hospital #1 failed to create and or assign medical record or patient account numbers to eight of twenty-six (8 of 26) randomly selected ED patients that presented to the ED between 11/16/2011 and 3/27/201. And ED staff failed to document attempts to assist Patient Identifier number one (PI # 1), a patient who arrived at the ED in an ambulance on 3/19/12, to secure transportation home after discharge.
These deficient practices affected 9 of 26 ED visits (PI's #1, #8, #9, #10, #14, #15, #21, # 22, and #23) of patients who presented to Hospital #1's ED between 11/16/2011 and 3/27/2012, and has potential to effect all individuals who present to Hospital #1's emergency department.

Findings Include:

During the survey (conducted 3/27-30/2012), twenty six (26) ED patient names were randomly selected from ED logs between 11/16/2011 and 3/27/2012. The surveyor found ED forms and documents relating to the emergency visits of PI #8, #9, #10, #14, #15, #21, #22 and #23's filed between the pages of the ED log for the month and year of the ED visit.
These records had no demographic face sheet , no medical record number, or patient account numbers.

Employee Identifier number one (EI #1), interviewed 3/29/2012 at 11:15 AM, was asked if all patients who come to Hospital #1's emergency department have assigned medical records. EI #1 replied, "When a patient comes in we provide a medical screening and decide what category and if we don't have the services, we will transfer the patient to a facility that has the services. For example, we don't have peds (pediatric) or OB (obstetric), if they (patients) are stable enough, we transfer those patients to our sister hospital (Hospital #3). If a patient is not stable we keep them until they are stabilized ..."

On 3/29/12 at 10:45 AM, the surveyor asked EI #2 if all patients presenting to the ED department have medical records. EI #2 replied, "...not if they (patients) are triaged out. If they are stable and can go to another facility, like...hospital (Hospital # 2). ...like a pediatric patient that would be better treated there ...or a rape victim ...if ...stable."

The surveyor reviewed the record of PI# 1, who presented to the ED by ambulance on 3/19/2012. Staff noted the patient arrived complaining of chest pain, was medically screened, received emergency treatment that included emergency dialysis, and prior to being discharged home. Staff noted PI #1's refused discharge and exhibited verbally hostile behavior toward the staff and physicians. Staff documented that hospital security came to the ED and assisted PI # 1 to the lobby, but failed to document, what if anything, was done to assure this patient had transportation home.

On 3/28/2012 at approximately 12:30PM, the surveyor viewed security video PI #1 after the patient was escorted out to the ED by security. The film shows a male identified as PI #1 seated in a wheelchair. The patient briefly talks on the hospital telephone while seated in the lobby at the registration desk, in the wheelchair. The patient rolls away from the desk and is next viewed seated in the wheelchair just outside the ED entrance door. PI# 1 is viewed seated outside the ED for more than 20 minutes and the camera moved to a new view of the hospital exterior. Hospital security reports the end of film showing PI #1 on this date. Security had no camera view that recorded when or how PI # 1 left the hospital grounds.

The security guards (EI # 7 and # 8) that assisted PI #1 out of the ED treatment area on 3/19/2012 were interviewed by telephone (on 3/29/2012 and 3/30/2012). The two security staff recalled helping PI #1 into the wheelchair and escorting PI #1 out of the ED. The security staff denied assisting or asking the patient if he (PI #1) had a way home. Security staff stated they did not see anyone to come to pick up PI # 1 and did not know when or how this patient left hospital grounds.

During an interview (on 3/29/12 at 9:45 AM), EI #3 said she (EI #3) offered to call someone to come and pick up PI #1, but PI #1 refused. There is no documentation by EI #3 or other staff members indicating staff attempted to assist PI #1 to secure transportation home.

Surveyor:
Barbara Little, RN