HospitalInspections.org

Based on observation, document review and interview, the facility staff failed to ensure they protected written documentation with patient confidential information for one (1) of one (1) patient, Patient #4.

The findings include:

During the initial tour of the Emergency Department (ED) on 11/16/2020 at approximately 1:10 P.M. with Staff Members #1 and #4, a clipboard with papers attached was observed lying on a biohazard waste can in a patient care room. There was no one in the room. The clipboard contained an almost full page of stickers with patient's name, date of birth, age and medical record number, and a document indicating Patient #4 was being assessed for symptoms of Covid-19.

Staff Member #4 stated, "They (Patient #4) are a First Responder and they are sent over periodically to be tested for Covid-19. That information should not have been left in the room."

Based on observation, and interview, the facility staff failed to ensure they followed the training received based on their infection control plan in three (3) of three (3) observed situations.

The findings include:

During the initial tour of the Emergency Department (ED) on 11/16/2020 at approximately 1:10 P.M. with Staff Members #1 and #4, the following observations were made:
Lobby: Three (3) patients or visitors were observed vacating the chairs they occupied in the lobby. The vacated chairs were not observed being cleaned and disinfected.

Patient Care Room: A clipboard made with compressed hardwood which absorbs water was observed lying on a biohazard waste can. Staff Member #4 stated, "I have been throwing all of those away (clipboards) when I find them. I must have missed that one."

Patient Care Room #2 in ED: Staff Member #8 was observed entering, leaving and re-entering a patient care room where a patient had arrived via ambulance. Staff Member #4 was asked what the protocol was for entering patient care rooms and stated, "They are to do hand hygiene before and after entering a patient care room."

Staff Member #7 (Infection Control Preventionist) was made aware of the findings on 11/17/2020 at approximately 11:30 A.M. and stated, "We have more education to do."

Based on document review and interview, the facility staff failed to ensure it was safe to place a patient (Patient #1) in the lobby unattended after discharge from the Emergency Department (ED), and failed to document notification of the transportation department and the patient's family prior to Patient #1's discharge.

The findings include:

Record review for Patient #1 revealed an elderly patient with a history of Deep Vein Thrombosis, Esophageal reflux, hypertension and breast cancer. EMS (Emergency Medical Services) was called to Patient #1's home. EMS documented Patient #1 was on their knees near the kitchen upon arrival. Patient #1 stated they were not currently sick but weak from not eating. Family reported to EMS, Patient #1 had been "feeling that way for the past few days." EMS brought Patient #1 to the facility on 4/18/2020 at approximately 5:34 P.M.

A review of Patient #1's medical record revealed the following:

Physician:
7:25 P.M. Spoke with Patient's daughter and stated vomiting X 2 days and today "collapsed" to floor, didn't pass out and no focal weakness.
8:38 P.M. Repeat troponin unchanged. No evidence of ACS (Acute Cardiac Symptoms). No evidence of dehydration. Patient tolerating p.o. (by mouth) intake. Home and no indication for admission will discharge home to daughter's care. Follow-up. Patient instructed that if they start vomiting and unable to keep anything down then return to ER (Emergency Room).
Registered Nurse:
8:55 P.M. Pain assessment 0, Patient discharged to home, Patient education completed, Patient was discharged via wheelchair with family, Valuables given to patient. Gave Rx (Prescription).
9:20 P.M. Called to lobby by triage nurse, attempts were made to get Patient into daughter's car when the daughter started calling out that the Patient was too weak to take home and wasn't right. Upon my arrival found Patient to be unresponsive to painful stimuli. Returned Patient to ER and Patient was vomiting could not expel. Oral suction started, and Patient noted to have dark brown drainage from nostril. Provider at bedside.

Staff Member #1 (Director of Patient Safety) stated, "At the time of Patient #1's admission to the ED the facility had put in place restrictions on who could be in the ED with the patients. No visitors were allowed."

Physician spoke with the family at approximately 7:25 P.M. The note timed 8:55 P.M. states Patient #1 was discharged via wheelchair to family, one hour and thirty (30) minutes after the physician documented they spoke with the family.
There was no documented evidence anyone spoke with the family or the facility's transportation department just prior to Patient #1's discharge to the lobby. There was no evidence anyone was in the lobby with Patient #1 until 9:20 P.M. Note timed 9:20 P.M. stated the family was attempting to place Patient #1 in the car when Patient #1 became unresponsive.