HospitalInspections.org

Based on record review and interview, the facility failed to ensure there is complete documentation of nursing assessments and/or MD notification, in 5 of 10 MRs reviewed (5, 6, 7, 8 and 10).

Findings include:

On 2/24/15 between 2:00 p.m. and 3:10 p.m. the following records were reviewed with DON A and CM C:

Pt #6's MR review revealed Pt #6 arrived in the ED on 1/2/15 at 7:47 p.m., with a complaint of swollen leg. There is no documentation of the MD being notified the Pt was in the ED. This was confirmed by CM C on 2/24/15 at 2:08 p.m., who agreed the time should be documented in the MR.

Pt #7's MR review revealed Pt #7 arrived in the ED on 1/2/15 at 6:33 p.m., with a complaint of sore throat. There is no documentation of the MD being notified the Pt was in the ED. There is no documentation of a nursing assessment, including Pt's complaint,other than vital signs. This was confirmed by CM C on 2/24/15 at 2:45 p.m., who agreed these should be documented in the MR.

Pt #8's MR review revealed Pt #8 arrived in the ED on 1/2/15 at 6:05 p.m. with a complaint of a respiratory infection. There is no documentation of the MD being notified the Pt was in the ED. This was confirmed by CM C on 2/24/15 at 2:55 p.m., who agreed the time should be documented in the MR.

Pt #10's MR review revealed Pt #10 arrived in the ED on 1/2/15 at 7:39 p.m. with a complaint of a rash. There is no documentation of the MD being notified the Pt was in the ED. There is no documentation of a nursing assessment, including Pt's complaint, other than vital signs. This was confirmed by CM C on 2/24/15 at 3:07 p.m., who agreed these should be documented in the MR.




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Pt. #5's closed ED MR was reviewed on 2/24/2015 at 2:55 p.m. accompanied by DON A who confirmed the following findings:

Pt. #5 arrived at the ED on 1/5/2015 at 5:17 p.m. The MD was notified that there was a new patient to be seen at 6:23 p.m. Pt. #5 was roomed into one of the ED rooms at 6:43 p.m. and, according to the ED log, left against medical advice at 7:50 p.m.

There is no documentation indicating that nursing completed a triage assessment or nursing assessment or that the MD completed a medical screening examination. There is also no form signed by Pt. #5 for leaving against medical advice.

In an interview with DON A on 2/24/2015 at 3:10 p.m., DON A stated, "There should be some sort of documentation in the record to indicate that this patient was taken back to a room in the ED but there is not."