HospitalInspections.org

Based on medical record review and staff interview, the facility failed to ensure all patients were provided a medical screening exam (A2406), stabilizing treatment (A2407), and appropriate transfer (A2409). The cumulative effect of this deficient practice resulted in the facility's inability to provide safe, effective care to all patients cared for in the Emergency Department.

Based on medical record review and staff interview the facility failed to provide a medical screening exam for one of 20 (Patient #12) patients reviewed.

Findings include:

1) The medical record review for Patient #12 was completed on 07/08/15. Patient #12 presented to the emergency department on 6/08/15 and was registered at 11:07 AM. This patient was entered into the log with a chief complaint of "needs dialysis". The triage note dated 06/08/15 at 11:38 AM revealed, "Instructed (patient) to go home and wait for dialysis center to notify him..." The medical record did not contain documentation of a medical screening exam prior to instructing the patient to return home.

This finding was confirmed with Staff A and Staff F on 07/08/15 at 10:45 AM.






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Based on medical record review and staff interview the facility failed to provide stabilizing treatment for an emergency medical condition for two of 20 (Patient #12 and 13) patients reviewed.

Findings include:


1) The medical record review for Patient #12 was completed on 07/08/15. Patient #12 presented to the emergency department on 06/08/15 and was registered at 11:07 AM. This patient was entered into the log with a chief complaint of "needs dialysis". The triage note dated 06/08/15 at 11:38 AM revealed, "Instructed (patient) to go home and wait for dialysis center to notify him..." The medical record did not contain documentation of a medical screening exam nor treatment should a emergency medical condition exist, prior to instructing the patient to return home.

This finding was confirmed with Staff A and Staff F on 07/08/15 at 10:45 AM.





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2) The medical record review for Patient #13 was completed on 07/08/15. The review revealed the patient presented to the emergency department on 06/18/15 at 8:45 AM with a chief complaint of right foot pain and stated he/she was looking for pain medicine until he/she was seen by his/her physician on 06/22/15. The review revealed a triage note that stated the patient rated the pain as a nine to 10 on a one to 10 scale, with 10 being the worst pain.

The medical record review revealed the patient was seen by the physician at 9:40 AM. The physician wrote that the patient had ankle surgery two weeks ago, and the patient was out of pain medications. The physician assessed the patient's right foot as having a short boot cast and positive movement, sensation and pulse. The physician noted he/she reviewed the nursing assessment which stated the nail beds were pink and the skin warm and dry.

The medical record review did not reveal any medications were given to treat the pain. The review revealed at 10:00 AM the patient was discharged. The review did not reveal what the patient's pain was at discharge. The review did reveal a primary diagnosis of narcotic seeking behavior and an additional one of foot pain.

On 07/08/15 at 9:30 AM in an interview, Staff F confirmed no pain medication was given, confirmed the diagnosis of drug seeking, and said the patient could have gone to the physician's office who did the surgery and couldn't believe all the local pharmacists would be unable to fill out a prescription.

Based on medical record review and staff interview the facility failed to ensure appropriate transfer for one of 20 (Patient #12) patients reviewed.

Findings include:


1) The medical record review for Patient #12 was completed on 07/08/15. Patient #12 presented to the emergency department on 06/08/15 and was registered at 11:07 AM. This patient was entered into the log with a chief complaint of "needs dialysis". The triage note dated 06/08/15 at 11:38 AM revealed, "Instructed (patient) to go home and wait for dialysis center to notify him..." The medical record did not contain documentation of a medical screening exam nor treatment should a emergency medical condition exist, or signature of a treating physician certifying the patient was informed of the risks/benefits of returning home, prior to instructing the patient to return home.

This finding was confirmed with Staff A and Staff F on 07/08/15 at 10:45 AM.




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Based on medical record review and staff interview the facility failed to provide a medical screening exam for one of 20 (Patient #12) patients reviewed.

Findings include:

1) The medical record review for Patient #12 was completed on 07/08/15. Patient #12 presented to the emergency department on 6/08/15 and was registered at 11:07 AM. This patient was entered into the log with a chief complaint of "needs dialysis". The triage note dated 06/08/15 at 11:38 AM revealed, "Instructed (patient) to go home and wait for dialysis center to notify him..." The medical record did not contain documentation of a medical screening exam prior to instructing the patient to return home.

This finding was confirmed with Staff A and Staff F on 07/08/15 at 10:45 AM.






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Based on medical record review and staff interview the facility failed to provide stabilizing treatment for an emergency medical condition for two of 20 (Patient #12 and 13) patients reviewed.

Findings include:


1) The medical record review for Patient #12 was completed on 07/08/15. Patient #12 presented to the emergency department on 06/08/15 and was registered at 11:07 AM. This patient was entered into the log with a chief complaint of "needs dialysis". The triage note dated 06/08/15 at 11:38 AM revealed, "Instructed (patient) to go home and wait for dialysis center to notify him..." The medical record did not contain documentation of a medical screening exam nor treatment should a emergency medical condition exist, prior to instructing the patient to return home.

This finding was confirmed with Staff A and Staff F on 07/08/15 at 10:45 AM.





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2) The medical record review for Patient #13 was completed on 07/08/15. The review revealed the patient presented to the emergency department on 06/18/15 at 8:45 AM with a chief complaint of right foot pain and stated he/she was looking for pain medicine until he/she was seen by his/her physician on 06/22/15. The review revealed a triage note that stated the patient rated the pain as a nine to 10 on a one to 10 scale, with 10 being the worst pain.

The medical record review revealed the patient was seen by the physician at 9:40 AM. The physician wrote that the patient had ankle surgery two weeks ago, and the patient was out of pain medications. The physician assessed the patient's right foot as having a short boot cast and positive movement, sensation and pulse. The physician noted he/she reviewed the nursing assessment which stated the nail beds were pink and the skin warm and dry.

The medical record review did not reveal any medications were given to treat the pain. The review revealed at 10:00 AM the patient was discharged. The review did not reveal what the patient's pain was at discharge. The review did reveal a primary diagnosis of narcotic seeking behavior and an additional one of foot pain.

On 07/08/15 at 9:30 AM in an interview, Staff F confirmed no pain medication was given, confirmed the diagnosis of drug seeking, and said the patient could have gone to the physician's office who did the surgery and couldn't believe all the local pharmacists would be unable to fill out a prescription.

Based on medical record review and staff interview the facility failed to ensure appropriate transfer for one of 20 (Patient #12) patients reviewed.

Findings include:


1) The medical record review for Patient #12 was completed on 07/08/15. Patient #12 presented to the emergency department on 06/08/15 and was registered at 11:07 AM. This patient was entered into the log with a chief complaint of "needs dialysis". The triage note dated 06/08/15 at 11:38 AM revealed, "Instructed (patient) to go home and wait for dialysis center to notify him..." The medical record did not contain documentation of a medical screening exam nor treatment should a emergency medical condition exist, or signature of a treating physician certifying the patient was informed of the risks/benefits of returning home, prior to instructing the patient to return home.

This finding was confirmed with Staff A and Staff F on 07/08/15 at 10:45 AM.




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