HospitalInspections.org

Based on staff interview, complaint report review, video observation, personnel record review, policy and procedure review, and Emergency Department (ED) medical record review, the facility failed to ensure Patient #22, one (1) of 22 ED patients reviewed, received a Medical Screening Exam (MSE) and stabilizing treatment when presenting to the ED.





Findings include:



Cross Refer to C2406 for the facility's failure to ensure Patient #22 was granted access to the ED and received a MSE related to his complaint of a Gun Shot Wound to his back.


Cross Refer to C2407 for the facility's failure to ensure Patient #22 received stabilization and treatment related to his complaint of a Gun Shot Wound to his back.



Cross Refer to C2408 for the facility's failure to ensure Patient #22 did not have a delay in treatment for a gunshot wound to his back.

Based on staff interview, complaint report review, video observation, personnel record review, policy and procedure review, and Emergency Department (ED) medical record review, the facility failed to ensure an appropriate Medical Screening Exam (MSE) within the capability of the hospital's ED was done for Patient #22, one (1) of 22 ED patients reviewed.


Findings include:

Review of a complaint received by the State Office revealed:
On 12/25/2014 between 1:38 and 1:45 a.m. Patient #22 presented to Hospital #1's ED door with a gunshot wound (GSW) to the back. The patient's family members stated that they knocked on the locked ED door and rang the door bell multiple times without gaining entry into the ED. After approximately 15 minutes of standing at the ED door trying to gain admittance, they left Hospital #1 and took the patient to the nearest hospital (Hospital #2) for treatment. Hospital #2 was approximately 25 to 30 minutes away from Hospital #1.



Review of a Complaint/Concern Form from Hospital #1 revealed:
Date/Time of Event: 12/31/14 1:30 a.m. (this was the date and time this complaint was called into the facility's Administrator and left on voicemail)
Complaint/Concern: Caller had brought brother...to ER (Emergency Room) with GSW. Stated door was locked and rang bell but no one ever responded. Carried brother to ER in Columbus. Brother's injuries were not life threatening and he is doing well now.
Investigation and Results: Staff had earlier noted to Administrator that someone had left that night without being seen but did not know who it was. All staff was busy on nursing floor with a code in progress. Advised pt's (patient's) sister that we had discussed and developed a protocol to prevent further occurences (occurrences).



Review of the Nurse Staffing Sheet for 1/24 - 25/14 revealed that there was one (1) Licensed Practical Nurse and three (3) Registered Nurses (RNs) on duty. Review of personnel records for RN #2, #3, and #4 revealed that all three were ACLS (Advanced Cardiac Life Support) certified.


During an interview on 1/20/15 at 12:40 p.m. the DON (Director of Nursing) was asked if there was a separate schedule for the ED and the in-patient unit. She stated, "There is not. I staff both together."


On 01/20/2015 at 1:05 p.m. a tour of the ED was conducted with the DON. Observation of the entrance to the ED revealed a button beside the door with instructions to press the button for assistance. The DON pressed the button multiple times. When the RN seated at the ED nursing station was asked if she heard the buzzer she stated that she had not. The DON pressed the buzzer again stating that she had not pressed it hard enough. Observation revealed a sign above the buzzer with instructions to press the button hard.


Interview with Hospital #1's Administrator on 1/20/15 at 2:55 p.m. revealed that he had received a telephone call from a person who said that she had brought her brother to the ED and could not get anyone to come to the door. The Administrator stated that on the night of 12/25/14 RN #2 was the supervisor and Ward Clerk #1 was on duty. While discussing the incident he stated, "The ward clerk should have dialed 911." When he was asked for the policy and procedure or protocol for this type of thing, he stated, "We don't have anything in writing."


Interview with RN #2 on 1/21/15 at 8:53 a.m. revealed that he came on duty Christmas Eve (12/24/14) and worked the night shift. "On 12/25/14 between 1:30- 2:00 a.m., as I was bringing a patient to the floor, I was notified of another in-patient having seizure activity. When I checked the patient (who was seizing), his defibrillator was going off. We coded the patient. All licensed staff responds to codes. About 20-30 minutes into the code, I was notified of a patient with a gunshot wound at the Emergency Room. By the time I got there, they were gone."


Telephone interview with Ward Clerk #1 on 1/21/15 at 9:10 a.m. revealed, "(On 12 /25/14) I was down the hall helping another patient. I heard the buzzer for the ED door and picked up the phone. I said 'May I help you, May I help you, May I help you.' They were cussing and fussing and could not hear me. I was pressing the button to let them in, but they were too close to the door. One of the people went over to the nursing home and told them to call the hospital and let them know that someone was at the door. At this point they pulled off."


Review of 12/25/14 video footage (no audio) from the hospital's ED entrance revealed that at 1:44 a.m. a car pulled into view of the ED camera. Four (4) people exited the car and proceeded to walk to the ED door. They pressed the button at the ED door multiple times. A male standing at the door was noted to be holding his left arm. At 1:45 a.m. a second car pulled into view of the camera. Three (3) people exited and made their way to the ED door. The button was again pressed multiple times. At 1:46 a.m. one of the people standing at the door again pressed the button multiple times. Also, at 1:46 a.m. a third car pulled into view. Four (4) people exited the car, two of them were males who were pushing at each other. All four (4) made their way to the ED door. At 1:47 a.m. a fourth car pulled into view of the camera. Two (2) people exited the car and made their way to the ED door. At 1:49 a.m. the button was again pressed multiple times and one (1) of the males was seen beating on the ED door. At 1:50 a.m. all 13 of the people who were gathered around the ED door left the doorway and walked back to their cars. At 1:51 a.m. they all left from view of the camera. The patient was noted to have been standing at the ED door for approximately six (6) minutes without gaining access and without receiving a Medical Screeing Exam (MSE), stabilization or treatment for a GSW to the back.


Review of the 12/25/14 video footage (with audio) from the inpatient nursing station revealed: The ED door buzzer sounded at the nursing station at 1:45 a.m. There was no one sitting at the nursing station. Ward Clerk #1 walked from the hallway into the nursing station and answered the call. She pressed the button to open the ED door and asked into the phone several times 'May I help you'. At 1:49 a.m. she left the nursing station. At 1:50 a.m., while re-entering the nursing station she stated, "I don't know what to do with all that fussing and fighting going on. I don't know what to do." At 1:53 a.m. the telephone rang at the nursing station and was answered by Ward Clerk #1. She stated into the phone, "I pushed the thing but they were all too close to the door."



Review of the facility's "Emergency Room Triage/Patient Flow" policy (review date 6/22/09) revealed, "Policy: ...Persons presenting for treatment are triaged by a registered nurse, with physician review and directed to either the emergency room or the rural health clinics. Those patients triaged as EMERGENT or URGENT will be directed to the emergency department and receive medical screening exams and treatment by the E.R. (Emergency Room) physician .... In the event the registered nurse is unable to do triage, a call can be placed to another registered nurse in the hospital to assist with triage until the triage nurse is available..."


Review of the facility's "Provision of Nursing Care" policy (issued 3/13/82) revealed, "A sufficient number of qualified registered nurses are on duty at all times to give patients the nursing care that requires the judgement and specialized skill of a registered nurse..."


Review of the facility's "Triage in the Emergency Room and Medical Screening" policy (revised 2/17/10) revealed, "Purpose: To ensure that all patients that come to the emergency room for treatment are triaged by a registered nurse and has a medical screening exam (MSE) by the ER physician for appropriate direction in care."


Review of the facility's "EMTALA - Mississippi Medical Screening Examination and Stabilization Policy", (Date: September 15, 2009) revealed, "Policy: An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED") and:
1. The individual or representative acting on the individual's behalf requests an examination or treatment for medical condition, or
2. A prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition."


Review of Patient #22's ED Medical Record from Hospital #2 revealed that he presented to their ED on 12/25/14 at 2:22 a.m. (31 minutes after leaving Hospital #1) with the complaint of a GSW to the back (left shoulder) and abrasion of right temple area. Patient reported being shot with a 22 caliber handgun from 30 feet away while he was attempting to break up a fight at a gas station. He was admitted into the ED as a trauma with an extry wound but no exit wound visualized. He reported constant pain from the GSW. He was examined, x-rayed, stabilized and treated in the ED. He was discharged home the same day.


On 02/06/2015 at 12:00 p.m. the Hospital Administrator was asked for the January 2015 Medical Staff Meeting minutes. Review of those minutes revealed no documented evidence of a discussion regarding the 12/25/14 occurance regarding the ED buzzer not being answered and the door not being opened to give Patient #22 admittance to the ED for a GSW.


During an interview on 02/06/2015 12:50 p.m. the Director of Nurses (DON) was asked if any in-services had been given to hospital/ED staff before the 12/25/2014 incident happened. She stated that she did not remember ever having an in-service on staff answering the ED buzzer/bell. "Everyone just knows to answer the door buzzer/bell when it rings. No one is assigned that procedure on a daily basis."

Based on staff interview, complaint report review, video observation, personnel record review, policy and procedure review, and Emergency Department (ED) medical record review, the facility failed to ensure Patient #22, one (1) of 22 ED patients reviewed, received the appropriate stabilization and treatment when presenting to the ED for a gunshot wound (GSW) to the back.



Findings include:





Review of a complaint received by the State Office revealed:
On 12/25/2014 between 1:38 and 1:45 a.m. Patient #22 presented to Hospital #1's ED door with a gunshot wound (GSW) to the back. The patient's family members stated that they knocked on the locked ED door and rang the door bell multiple times without gaining entry into the ED. After approximately 15 minutes of standing at the ED door trying to gain admittance, they left Hospital #1 and took the patient to the nearest hospital (Hospital #2) for treatment. Hospital #2 was approximately 25 to 30 minutes away from Hospital #1.



Review of a Complaint/Concern Form from Hospital #1 revealed:
Date/Time of Event: 12/31/14 1:30 a.m. (this was the date and time this complaint was called into the facility's Administrator and left on voicemail)
Complaint/Concern: Caller had brought brother...to ER (Emergency Room) with GSW. Stated door was locked and rang bell but no one ever responded. Carried brother to ER in Columbus. Brother's injuries were not life threatening and he is doing well now.
Investigation and Results: Staff had earlier noted to Administrator that someone had left that night without being seen but did not know who it was. All staff was busy on nursing floor with a code in progress. Advised pt's (patient's) sister that we had discussed and developed a protocol to prevent further occurences (occurrences).



Review of the Nurse Staffing Sheet for 1/24 - 25/14 revealed that there was one (1) Licensed Practical Nurse and three (3) Registered Nurses (RNs) on duty. Review of personnel records for RN #2, #3, and #4 revealed that all three were ACLS (Advanced Cardiac Life Support) certified.


During an interview on 1/20/15 at 12:40 p.m. the DON (Director of Nursing) was asked if there was a separate schedule for the ED and the in-patient unit. She stated, "There is not. I staff both together."


On 01/20/2015 at 1:05 p.m. a tour of the ED was conducted with the DON. Observation of the entrance to the ED revealed a button beside the door with instructions to press the button for assistance. The DON pressed the button multiple times. When the RN seated at the ED nursing station was asked if she heard the buzzer she stated that she had not. The DON pressed the buzzer again stating that she had not pressed it hard enough. Observation revealed a sign above the buzzer with instructions to press the button hard.


Interview with Hospital #1's Administrator on 1/20/15 at 2:55 p.m. revealed that he had received a telephone call from a person who said that she had brought her brother to the ED and could not get anyone to come to the door. The Administrator stated that on the night of 12/25/14 RN #2 was the supervisor and Ward Clerk #1 was on duty. While discussing the incident he stated, "The ward clerk should have dialed 911." When he was asked for the policy and procedure or protocol for this type of thing, he stated, "We don't have anything in writing."


Interview with RN #2 on 1/21/15 at 8:53 a.m. revealed that he came on duty Christmas Eve (12/24/14) and worked the night shift. "On 12/25/14 between 1:30- 2:00 a.m., as I was bringing a patient to the floor, I was notified of another in-patient having seizure activity. When I checked the patient (who was seizing), his defibrillator was going off. We coded the patient. All licensed staff responds to codes. About 20-30 minutes into the code, I was notified of a patient with a gunshot wound at the Emergency Room. By the time I got there, they were gone."


Telephone interview with Ward Clerk #1 on 1/21/15 at 9:10 a.m. revealed, "(On 12 /25/14) I was down the hall helping another patient. I heard the buzzer for the ED door and picked up the phone. I said 'May I help you, May I help you, May I help you.' They were cussing and fussing and could not hear me. I was pressing the button to let them in, but they were too close to the door. One of the people went over to the nursing home and told them to call the hospital and let them know that someone was at the door. At this point they pulled off."


Review of 12/25/14 video footage (no audio) from the hospital's ED entrance revealed that at 1:44 a.m. a car pulled into view of the ED camera. Four (4) people exited the car and proceeded to walk to the ED door. They pressed the button at the ED door multiple times. A male standing at the door was noted to be holding his left arm. At 1:45 a.m. a second car pulled into view of the camera. Three (3) people exited and made their way to the ED door. The button was again pressed multiple times. At 1:46 a.m. one of the people standing at the door again pressed the button multiple times. Also, at 1:46 a.m. a third car pulled into view. Four (4) people exited the car, two of them were males who were pushing at each other. All four (4) made their way to the ED door. At 1:47 a.m. a fourth car pulled into view of the camera. Two (2) people exited the car and made their way to the ED door. At 1:49 a.m. the button was again pressed multiple times and one (1) of the males was seen beating on the ED door. At 1:50 a.m. all 13 of the people who were gathered around the ED door left the doorway and walked back to their cars. At 1:51 a.m. they all left from view of the camera. The patient was noted to have been standing at the ED door for approximately six (6) minutes without gaining access and without receiving a Medical Screeing Exam (MSE), stabilization or treatment for a GSW to the back.


Review of the 12/25/14 video footage (with audio) from the inpatient nursing station revealed: The ED door buzzer sounded at the nursing station at 1:45 a.m. There was no one sitting at the nursing station. Ward Clerk #1 walked from the hallway into the nursing station and answered the call. She pressed the button to open the ED door and asked into the phone several times 'May I help you'. At 1:49 a.m. she left the nursing station. At 1:50 a.m., while re-entering the nursing station she stated, "I don't know what to do with all that fussing and fighting going on. I don't know what to do." At 1:53 a.m. the telephone rang at the nursing station and was answered by Ward Clerk #1. She stated into the phone, "I pushed the thing but they were all too close to the door."



Review of the facility's "Emergency Room Triage/Patient Flow" policy (review date 6/22/09) revealed, "Policy: ...Persons presenting for treatment are triaged by a registered nurse, with physician review and directed to either the emergency room or the rural health clinics. Those patients triaged as EMERGENT or URGENT will be directed to the emergency department and receive medical screening exams and treatment by the E.R. (Emergency Room) physician .... In the event the registered nurse is unable to do triage, a call can be placed to another registered nurse in the hospital to assist with triage until the triage nurse is available..."


Review of the facility's "Provision of Nursing Care" policy (issued 3/13/82) revealed, "A sufficient number of qualified registered nurses are on duty at all times to give patients the nursing care that requires the judgement and specialized skill of a registered nurse..."


Review of the facility's "Triage in the Emergency Room and Medical Screening" policy (revised 2/17/10) revealed, "Purpose: To ensure that all patients that come to the emergency room for treatment are triaged by a registered nurse and has a medical screening exam (MSE) by the ER physician for appropriate direction in care."


Review of the facility's "EMTALA - Mississippi Medical Screening Examination and Stabilization Policy", (Date: September 15, 2009) revealed, "Policy: An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED") and:
1. The individual or representative acting on the individual's behalf requests an examination or treatment for medical condition, or
2. A prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition."


Review of Patient #22's ED Medical Record from Hospital #2 revealed that he presented to their ED on 12/25/14 at 2:22 a.m. (31 minutes after leaving Hospital #1) with the complaint of a GSW to the back (left shoulder) and abrasion of right temple area. Patient reported being shot with a 22 caliber handgun from 30 feet away while he was attempting to break up a fight at a gas station. He was admitted into the ED as a trauma with an extry wound but no exit wound visualized. He reported constant pain from the GSW. He was examined, x-rayed, stabilized and treated in the ED. He was discharged home the same day.

On 02/06/2015 at 12:00 p.m. the Hospital Administrator was asked for the January 2015 Medical Staff Meeting minutes. Review of those minutes revealed no documented evidence of a discussion regarding the 12/25/14 occurance regarding the ED buzzer not being answered and the door not being opened to give Patient #22 admittance to the ED for a GSW.


During an interview on 02/06/2015 12:50 p.m. the Director of Nurses (DON) was asked if any in-services had been given to hospital/ED staff before the 12/25/2014 incident happened. She stated that she did not remember ever having an in-service on staff answering the ED buzzer/bell. "Everyone just knows to answer the door buzzer/bell when it rings. No one is assigned that procedure on a daily basis."

Based on staff interview, complaint report review, video observation, personnel record review, policy and procedure review, and Emergency Department (ED) medical record review, the facility failed to ensure Patient #22, one (1) of 22 ED patients reviewed, received the appropriate stabilization and treatment without delay when presenting to the ED for a gunshot wound (GSW) to the back. A delay in treatment was caused when the patient could not gain access to the ED and had to be taken to a different hospital 31 minutes away.



Findings include:



Review of a complaint received by the State Office revealed:
On 12/25/2014 between 1:38 and 1:45 a.m. Patient #22 presented to Hospital #1's ED door with a gunshot wound (GSW) to the back. The patient's family members stated that they knocked on the locked ED door and rang the door bell multiple times without gaining entry into the ED. After approximately 15 minutes of standing at the ED door trying to gain admittance, they left Hospital #1 and took the patient to the nearest hospital (Hospital #2) for treatment. Hospital #2 was approximately 25 to 30 minutes away from Hospital #1 causing a delay in treatment.



Review of a Complaint/Concern Form from Hospital #1 revealed:
Date/Time of Event: 12/31/14 1:30 a.m. (this was the date and time this complaint was called into the facility's Administrator and left on voicemail)
Complaint/Concern: Caller had brought brother...to ER (Emergency Room) with GSW. Stated door was locked and rang bell but no one ever responded. Carried brother to ER in Columbus. Brother's injuries were not life threatening and he is doing well now.
Investigation and Results: Staff had earlier noted to Administrator that someone had left that night without being seen but did not know who it was. All staff was busy on nursing floor with a code in progress. Advised pt's (patient's) sister that we had discussed and developed a protocol to prevent further occurences (occurrences).



Review of the Nurse Staffing Sheet for 1/24 - 25/14 revealed that there was one (1) Licensed Practical Nurse and three (3) Registered Nurses (RNs) on duty. Review of personnel records for RN #2, #3, and #4 revealed that all three were ACLS (Advanced Cardiac Life Support) certified.


During an interview on 1/20/15 at 12:40 p.m. the DON (Director of Nursing) was asked if there was a separate schedule for the ED and the in-patient unit. She stated, "There is not. I staff both together."


Interview with Hospital #1's Administrator on 1/20/15 at 2:55 p.m. revealed that he had received a telephone call from a person who said that she had brought her brother to the ED and could not get anyone to come to the door. The Administrator stated that on the night of 12/25/14 RN #2 was the supervisor and Ward Clerk #1 was on duty. While discussing the incident he stated, "The ward clerk should have dialed 911." When he was asked for the policy and procedure or protocol for this type of thing, he stated, "We don't have anything in writing."


On 01/20/2015 at 1:05 p.m. a tour of the ED was conducted with the DON. Observation of the entrance to the ED revealed a button beside the door with instructions to press the button for assistance. The DON pressed the button multiple times. When the RN seated at the ED nursing station was asked if she heard the buzzer she stated that she had not. The DON pressed the buzzer again stating that she had not pressed it hard enough. Observation revealed a sign above the buzzer with instructions to press the button hard.


Interview with RN #2 on 1/21/15 at 8:53 a.m. revealed that he came on duty Christmas Eve (12/24/14) and worked the night shift. "On 12/25/14 between 1:30- 2:00 a.m., as I was bringing a patient to the floor, I was notified of another in-patient having seizure activity. When I checked the patient (who was seizing), his defibrillator was going off. We coded the patient. All licensed staff responds to codes. About 20-30 minutes into the code, I was notified of a patient with a gunshot wound at the Emergency Room. By the time I got there, they were gone."


Telephone interview with Ward Clerk #1 (who is also a Nurse Aide) on 1/21/15 at 9:10 a.m. revealed, "(On 12 /25/14) I was down the hall helping another patient. I heard the buzzer for the ED door and picked up the phone. I said 'May I help you, May I help you, May I help you.' They were cussing and fussing and could not hear me. I was pressing the button to let them in, but they were too close to the door. One of the people went over to the nursing home and told them to call the hospital and let them know that someone was at the door. At this point they pulled off."


Review of 12/25/14 video footage (no audio) from the hospital's ED entrance revealed that at 1:44 a.m. a car pulled into view of the ED camera. Four (4) people exited the car and proceeded to walk to the ED door. They pressed the button at the ED door multiple times. A male standing at the door was noted to be holding his left arm. At 1:45 a.m. a second car pulled into view of the camera. Three (3) people exited and made their way to the ED door. The button was again pressed multiple times. At 1:46 a.m. one of the people standing at the door again pressed the button multiple times. Also, at 1:46 a.m. a third car pulled into view. Four (4) people exited the car, two of them were males who were pushing at each other. All four (4) made their way to the ED door. At 1:47 a.m. a fourth car pulled into view of the camera. Two (2) people exited the car and made their way to the ED door. At 1:49 a.m. the button was again pressed multiple times and one (1) of the males was seen beating on the ED door. At 1:50 a.m. all 13 of the people who were gathered around the ED door left the doorway and walked back to their cars. At 1:51 a.m. they all left from view of the camera. The patient was noted to have been standing at the ED door for approximately six (6) minutes without gaining access and without receiving a Medical Screeing Exam (MSE), stabilization or treatment for a GSW to the back.


Review of the 12/25/14 video footage (with audio) from the inpatient nursing station revealed: The ED door buzzer sounded at the nursing station at 1:45 a.m. There was no one sitting at the nursing station. Ward Clerk #1 (Nurse Aide) walked from the hallway into the nursing station and answered the call. She pressed the button to open the ED door and asked into the phone several times 'May I help you'. At 1:49 a.m. she left the nursing station. At 1:50 a.m., while re-entering the nursing station she stated, "I don't know what to do with all that fussing and fighting going on. I don't know what to do." At 1:53 a.m. the telephone rang at the nursing station and was answered by Ward Clerk #1. She stated into the phone, "I pushed the thing but they were all too close to the door."



Review of the facility's "Emergency Room Triage/Patient Flow" policy (review date 6/22/09) revealed, "Policy: ...Persons presenting for treatment are triaged by a registered nurse, with physician review and directed to either the emergency room or the rural health clinics. Those patients triaged as EMERGENT or URGENT will be directed to the emergency department and receive medical screening exams and treatment by the E.R. (Emergency Room) physician .... In the event the registered nurse is unable to do triage, a call can be placed to another registered nurse in the hospital to assist with triage until the triage nurse is available..."


Review of the facility's "Provision of Nursing Care" policy (issued 3/13/82) revealed, "A sufficient number of qualified registered nurses are on duty at all times to give patients the nursing care that requires the judgement and specialized skill of a registered nurse..."


Review of the facility's "Triage in the Emergency Room and Medical Screening" policy (revised 2/17/10) revealed, "Purpose: To ensure that all patients that come to the emergency room for treatment are triaged by a registered nurse and has a medical screening exam (MSE) by the ER physician for appropriate direction in care."


Review of the facility's "EMTALA - Mississippi Medical Screening Examination and Stabilization Policy", (Date: September 15, 2009) revealed, "Policy: An EMTALA obligation is triggered when an individual comes to a dedicated emergency department ("DED") and:
1. The individual or representative acting on the individual's behalf requests an examination or treatment for medical condition, or
2. A prudent layperson observer would conclude from the individual's appearance or behavior that the individual needs an examination or treatment of a medical condition."


Review of Patient #22's ED Medical Record from Hospital #2 revealed that he presented to their ED on 12/25/14 at 2:22 a.m. (31 minutes after leaving Hospital #1) with the complaint of a GSW to the back (left shoulder) and abrasion of right temple area. Patient reported being shot with a 22 caliber handgun from 30 feet away while he was attempting to break up a fight at a gas station. He was admitted into the ED as a trauma with an extry wound but no exit wound visualized. He reported constant pain from the GSW. He was examined, x-rayed, stabilized and treated in the ED. He was discharged home the same day.


On 02/06/2015 at 12:00 p.m. the Hospital Administrator was asked for the January 2015 Medical Staff Meeting minutes. Review of those minutes revealed no documented evidence of a discussion regarding the 12/25/14 occurance regarding the ED buzzer not being answered and the door not being opened to give Patient #22 admittance to the ED for a GSW.


During an interview on 02/06/2015 12:50 p.m. the Director of Nurses (DON) was asked if any in-services had been given to hospital/ED staff before the 12/25/2014 incident happened. She stated that she did not remember ever having an in-service on staff answering the ED buzzer/bell. "Everyone just knows to answer the door buzzer/bell when it rings. No one is assigned that procedure on a daily basis."