HospitalInspections.org

Based on a review of records, documentation, and interview, it was determined that the facility governing body failed to ensure that current rules for the medical staff were implemented and enforced.

Findings were:

Facility based policy entitled, "Standards of Practice" stated in part, "The patient assessment is completed within 15 minutes after admission to the treatment area and includes: ...
? Discharge assessments completed by the Registered Nurse include: ...
...Related Standards of Patient Care: ...
? The patient will receive a comprehensive assessment within 15 minutes after admission to the treatment area by a Registered Nurse ...
STANDARD VII:
? The Emergency Department RN triages every patient that presents to the Emergency Department. The Emergency Department RN determines the priority of care to facilitate patient flow through the emergency care system."

Facility based policy entitled, "Assessment of the Emergency Department Patient" stated in part, "All patients presenting to the Emergency Department will be triaged and categorized as either Level 1 Emergent, Level 2 Emergent, Level 3, Level 4, or level 5 Clinical."

Facility based policy entitled, "Triage" stated in part, "The registered nurse will evaluate and categorize each patient upon arrival to the Emergency Department into either resuscitative, emergency, urgent, semi-urgent or routine categories."

A facility based document entitled "LVN Scope of Practice in the Emergency Room" was observed posted in the Emergency Department during a tour of the facility on 01/03/13. This document stated in part,
"LVN ' s cannot triage patients.
Triage-
a. The process of determining the priority of the patient ' s treatment based on the severity of their condition.
b. A process of sorting injured/sick patients into groups based on their need or likely benefit from immediate treatment.
This includes assigning a triage level; an RN, PA or Doctor must assign a triage level to the EMAR ...
LVN ' s should not be doing an initial assessment on an ED pt, unless there are extenuating circumstances. (If this occurs an RN must sign off that he/she agrees with the assessment.)"

In a review of medical charts, 5 out of 10 Emergency Department patient records were found to have issues involving documentation.
? On patient # 1, the triage and discharge assessment portions of the record were completed by a paramedic.
? On patient # 5, the triage portion of the record was completed and an acuity level of 3 assigned by an LVN.
? Patients # 6, 7, and 8 had the triage and discharge assessment portions of the record completed by an LVN.

According to facility based policy, documents, and interview only registered nurses are to complete triage and intial assessments. According to policy, only registered nurses are to complete discharge assessments on patients in the Emergency Department.

The above findings were confirmed with staff member # 2 on 01/09/14.

Based on a review of records, documentation, and interview, it was determined that the facility failed to ensure policies regarding the administration of drugs and biologicals.

Findings were:

Facility based policy entitled, "Drug Administration" stated in part,
"I. Drug Administration
A. RN, GN, LVN, GVN, SVN
B. All medications must be administered by the person preparing the medication (unless prepared by the pharmacist); in which instances licensed personnel may administer."

Review of the medical chart for Patient #3 revealed that on 12/31/13 at 13:05 a paramedic administered an intravenous push of the following medication: "Furosemide IVP 40 mg given over 2 minute(s) via site # 1."

In an interview on 01/08/14, staff member # 2 confirmed that paramedics are not to administer intravenous medication in the emergency department.