HospitalInspections.org

Based on the review of 20 medical records, staff interview, and review of the Emergency Department (ED) log, it was determined that the facility failed to maintain an accurate central log on each individual who comes to the ED.

Findings include:

1. Twenty (20) medical records were reviewed and it was noted in 8 out of 20 medical records, there were discrepancies between the medical record and the associated ED log.

2. The medical record of Patient #1 indicated on 1/31/18 at 12:10 PM on the "Emergency Department Depart Summary" that the disposition was "Home." The corresponding ED log listed Patient #1 as "discharged." Patient #1 was transferred.

3. The medical record of Patient #4 indicated on 2/3/18 at 3:55 PM on the "Emergency Department Depart Summary" that the disposition was "Admitted." The corresponding ED log listed Patient #4 as "___ ___ University Hospital Admitted."

a. Patient #4 was admitted to the facility on 2/3/18 at 3:55 PM.

b. Patient #4 was transferred to another facility on 2/4/18 at 2:56 PM.

c. The ED log for Patient #4 reflected both the ED disposition and the disposition of the patient after admission.

4. The medical record of Patient #5 indicated on the "Emergency Department Discharge Summary" under the "Events Information" section, the discharge date and time of 2/4/18 at 4:53 PM. The corresponding ED log for the patient notes the discharge date and time as 2/4/18 4:15 PM.

a. An interview with Staff #9 indicated that "there are two separate systems for tracking ED patients. The discrepancies could occur if a patient is discharged and the registered nurse does not discharge the patient in both systems. To correct this, the nurse would have to backtrack the date and time, so that both the discharge times would be the same."

b. Staff #9 agreed that the discharge time in Medical Record #5 was not the same as the discharge time on the ED log, and that the discharge times should be the same.

5. The medical record of Patient #6 indicated:

a. On 2/5/18 at 10:56 AM, in the "Emergency Department Note - Physician," the mode of arrival was "Private Vehicle." The ED log lists an ambulance service as the mode of arrival.

b. On 2/6/18 at 12:33 AM, in the "Emergency Department Note - Physician," written by Staff #10, the disposition of Patient #6 was "Discharged: to home." The corresponding ED log noted the patient disposition was "Elopement."

6. The medical record of Patient #13 indicated on 10/4/17 at 5:12 PM on the "Emergency Department Depart Summary" that the patient disposition was "Admitted." The corresponding ED log noted Patient #13 as "___ ___ ___ Care Center Admitted."

a. Patient #13 was admitted to the facility on 10/4/17 at 5:12 PM.

b. Patient #13 was transferred to another facility on 10/9/17 at 12:53 PM.

c. The ED log for Patient #13 reflects both the ED disposition and the disposition of the patient after admission.

7. The medical record of Patient #15 was noted to have an order to discharge from the ED written on 10/3/18 at 4:30 PM. The corresponding ED log listed Patient #15's disposition as "Still a patient - Procedure."

8. The medical record of Patient #11 indicated that the patient was treated in the emergency department on 9/2/17. The patient was placed on observation status and discharged the following day. The Disposition section of the ED Log stated that the patient was "Admitted."

9. The medical record of Patient #18 indicated that the patient was admitted to the facility from the ED on 12/21/17. The Disposition section of the ED Log indicated that the patient was transferred to another facility.

10. An interview with Staff #4 revealed that the facility does not have a current policy on the maintenance and development of the ED log.

Based on a review of facility policy and procedure, review of the medical records of 2 of 20 patients who presented to the emergency department (ED), review of the on-call schedules, and interview with administrative staff, it was determined that not all individuals who came to the emergency department are provided with an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed.

Findings include:

Reference #1: Facility policy titled "Medical Staff On-Call for Unassigned Patients" stated:
"Objective: To provide a process by which physicians are available to provide evaluation and or treatment to stabilize an individual with an emergency medical condition including a plan when the on-call physician cannot respond.
.....
Procedure:
The On-Call Policy covers all aspects of provider on-call to Hospital's Emergency Department patients (defined to include those seen in 'fast track' and 'quickcare' portion of the Emergency Department as well as all emergent [sic] of CDU (Clinical Decision Unit), but excluding patients in the outpatient or off-site setting of Hospital) including response times, failure to respond in a timely manner, maintenance of the call schedules, the process for contacting a practitioner or requesting an onsite evaluation of a patient.

All active and affiliate members of the medical staff are obligated by virtue of that membership to serve on the on-call schedule and to participate in providing emergency room call and other coverage arrangements for emergency and to meet the needs of the community in accordance with physician resources and as defined in the Medical Staff Bylaws and policies adopted by the Medical Executive Committee ("MEC") and Board of Trustees.

If a physician is not able to meet the on-call schedule requirement, the physician will need to make arrangements with another physician with same privileges to provide that coverage.
Physicians may schedule elective surgery while on-call however, the physician must arrange for coverage with another same specialty physician in case he/she is unable to attend to an emergency/urgent need during that time. Any physician who is unable to respond to call is responsible to notify the hospital emergency room and ensure qualified coverage by a physician on the medical staff with the same privileges.
.....
All on-call physicians must be available and accessible and shall use best efforts to respond by telephone within (fifteen) 15 minutes of receiving a call made by the Hospital's emergency department. The on-call physician and the emergency department physician must have a discussion about the patient's condition and agree upon an appropriate in person response time based on clinical necessity. If the on-call physician and the emergency department physician are unable to reach an agreement as to the appropriate in-person response time, then the opinion of the emergency department physician, who is present at the Hospital, shall govern. Notwithstanding the foregoing, the in-person response time by the on-call physician for a patient who is eighteen years or younger shall be no longer than sixty (60) minutes after the initial physician to physician contact.
.....
Emergency Department
A physician on the division/department call rotation schedule shall be contacted as follows:
.....
b. the ED physician or contacting staff shall document in the patient's medical record the name of the physician who was contacted, number utilized and the time contact was made with the physician; and physician's verbal response.
....."

Reference #2: The ARTICLE III - CATEGORIES OF MEDICAL STAFF MEMBERSHIP section of SHORE MEDICAL CENTER MEDICAL STAFF BYLAWS stated:
".....
Section 3.1 Active Staff
.....
RESPONSIBILITIES: Appointees to this category must:
.....
3.1.5 Participate in providing Emergency Room Call and other coverage arrangements as defined in policies adopted by the MEC and Board.
....."

Reference #3: The "Cardiology ER On Call January 2018" schedule indicated that Staff #10 was the on-call cardiologist on 1/31/18.

Reference #4: Policy titled "Evaluation of a Patient with Stroke / TIA (Transient Ischemic Attack) Symptoms Presenting to the Emergency Department" stated:
"Objective: To rapidly identify patients who meet the criteria for Fibrinolytics (tPA)
.....
Policy:
When a patient presents to the ED with signs or symptoms related to Stroke / TIA:
1. If the patient presents to the ED ambulatory:
- The Triage Nurse will immediately notify Clinical Supervisor/ Charge Nurse for STAT (immediate) placement. The Primary Care Nurse or Clinical Supervisor/Charge Nurse will activate the ED Stroke Alert Team and notify the ED physician of the patient's arrival
- The ATP (Advanced Treatment Protocol) Hyperacute/Acute Stroke Standing Orders will be initiated by the nurse or the ED physician will initiate the appropriate Stroke Power Plan.
- The patient will be transported directly by an Emergency Department RN to CT (Computerized Tomography) [sic] for a STAT CT of the head(.)
.....
3. All patients presenting with signs or symptoms of Stroke will be an ESI (Emergency Severity Index) minimum of 2, even if currently asymptomatic. Any patients presenting within the 4.5 hour window are made an ESI 1 requiring immediate intervention.
4. After the STAT Head CT is completed, before leaving the CT Room the Stroke Panel and POC (Point-of-Care) Glucose will be obtained, labeled appropriately, and immediately shuttled to the lab followed by a telephone call to the lab tech informing of the STAT Stroke Panel shuttled.
5. For a Hyperacute Stroke Evaluation, a Portable CXR should be done while in the CT room or when the patient returns to the roomed treatment area
6. When the CT is completed, the patient will go from the CT table directly to the bed or stretcher with a bed scale to obtain an accurate weight in kilograms
7. The patient will be transported to an assigned ED treatment room and the Stroke evaluation will be completed including: IV (Intravenous), Cardiac Monitoring, Pulse Oximetery, Vital Signs, NIHSS (National Institutes of Health Stroke Scale) Neuro Assessment and documentation of triage. Pharmacy needs immediate notification of the potential tPA patient
8. The nurse will follow the Stroke Algorithm and document appropriately in the EMR
9. If the physician determines Teleneurology will be consulted, the nurse will enter the data into the StrokeRESPOND and follow the Emergency Department Algorithm for Teleneurology.
10. If tPA is to be used, the Nurse will notify the pharmacist on duty to prepare the tPA and prepare for the administration of IV tPA following the tPA monitoring protocol
11. If the physician ids evaluating the patient for and Acute Stroke Evaluation, the Primary Care Nurse will follow the Provider Order Entry for Acute Stroke Evaluation. Remember the urgency for STAT Stroke Panel Blood work and CT Scan of the head, as an Acute Stroke Patient can turn into a Hyperacute Stroke Patient.
12. For any problems encountered, inform the ED Clinical Supervisor / Charge Nurse on Duty and the Emergency Department Physician.
13. Document appropriately in the medical record.
....."

Reference #5: The section of policy titled "Emergency Medical Screening, Stabilizing Treatment, and Transfer and On Call" stated:
".....
G. Consultations and Referrals Prior to the Patient Stabilization and Discharge.
.....
For patients requiring the care of a specialist, the rotation call list containing the names and phone numbers of the on call specialist physicians which shall be posted in the ED, will be used to select a physician to provide the necessary specialty care, consultation and treatment for the patient. Physicians shall comply with the Hospital's On-Call Policy. If an on call physician fails or refuses to appear within 30 minutes of the initial contact by SMC, and the ED physician orders the transfer of the patient because he or she determines that without the services of the on call physician the benefits of transfer outweigh the risks of transfer, the physician authorizing the transfer shall not be subject to penalty or discipline. ....."

Reference #6: Facility policy titled, "Triage of Patients in the Emergency Department" states, " ... Procedure: ... 9. In the unlikely event that triage may be delayed greater than 15 minutes, clinical supervisor or Charge RN will initiate rapid triage function, increasing staffing if warranted and/or facilitate direct bedding of patients ....."

1. Review of the emergency department medical record of Patient #1 dated 1/31/18 revealed:

a. "Chief Complaint from Nursing Triage Note - Chief Complaint Description" stated: "PER DR _____ (Staff #10) PT (Patient) SENT FROM STRESS (test) WITH QUESTIONABLE MI (Myocardial Infarction). ON ARRIVAL TO ER PT VIA FAMILY STATES CHEST PAIN RADIATING INTO LEFT ARM AND SOB (Shortness Of Breath) DURING TEST AND BEING TRANSFERRED." The Associated Diagnosis was documented by the physician as: "ST (segment) elevation MI (STEMI); Chest pain: Abnormal stress test.

b. The "History of Present Illness" section stated: "The patient presents with chest pain, pt [patient] failed stress test per Dr _____ [Staff #10] (chest pain and EKG (electrocardiogram) changes - st (ST) elevation and depressions) and needed acute transfer to cath lab for AMI [Acute Myocardial Infarction] intervention - pt received by ED staff - pt transported to Ed [sic] by Security, no nurse, no monitor, no cardiologist. Information obtained from family, and EKG from stress test and pt reported pain is decreasing that (he/she) experienced during stress test. ....."

c. A NURSING CLINICAL NOTE stated: "EKG changes noted by Dr _____ (Staff #10). Patient transfer via stretcher with O2 (Oxygen) 2l (2 liters) n/c (nasal cannula) to the ER (Emergency Room) as ordered by Dr. _____ (Staff #10) for ST elevation(.)"

d. The "Calls-Consults" section stated: "..... Dr. _____ refused to come to ED with pt or to see pt in ED." The entry was made by the ED physician who requested that the sending physician, who was also the on-call cardiologist, come to the emergency department to see the patient.

(i) Staff #10 failed to come to the emergency department as the on-call cardiologist, to consult, when requested to do so by the treating emergency department physician. Administrator #4 stated that the cardiologist is a member of the Active Medical Staff.

(ii) Administrator #4 agreed with the findings.

2. Review of the emergency department medical record of Patient #17 dated 12/5/17 revealed:

a. The EVENTS INFORMATION section indicated that the patient arrived in the emergency department at 11:38 AM, was triaged at 11:52 AM, and examined by the physician at 1:11 PM.

b. The "Chief Complaint" section of the "Triage Assessment" stated: "pt [patient] here with friend states wife called her this am (morning) and stated that pt is having severe intermittent memory loss. pt has no complaints states nothing out of the ordinary. pt states under extreme stress with wifes [sic] recent surgery." His blood pressure was 169/82 in triage. The patient was assigned an ESI classification of "3."

c. The "History of Present Illness" section of the ED physician documentation stated: "The patient presents with memory loss. Pt presents to ED with his friend who drove him here b/c (because) at 10:30am he had memory loss which is what he told triage(.)
The ED is very busy and I saw the pt as soon as possible
he had no complaints here and was back to baseline but when I asked him to expalin [sic] what happened his friend said he all the [sic] sudden became confused and couldn't [sic] answer questions correctly and couldn't [sic] remember the yr (year) or that his wife just had surgery
this episode lasted 20 minutes and then completely resolved
denies HA (headache), CP (chest pain), abd (abdominal) pain, N/V/D (nausea, vomiting, diarrhea)
last known normal 10:30am
based on the description they gave me I am starting a stroke protocol on him."

d. The "Clinical Discharge Summary" stated:
"Reason for Visit
General medical: Altered mental status: TRANSIENT CEREBRAL ISCHEMIC ATTACK
Impression
Brain TIA: Transient global amnesia; uncontrolled hypertension"

e. The "Hospital Course" section of the DISCHARGE DOCUMENTATION stated:
"Patient is a pleasant 69-year-old Caucasian male with history of hypertension and prostate cancer. He was in his usual state of health until the morning when he started talking to his wife and she noticed that he has some memory issue and could not remember the name of the hospital that she had her surgery done recently [sic] or he could not name the food and so on. Patient was sent to emergency room for evaluation of his symptoms and to rule out TIA. He had a CAT scan of head in the emergency room and admitted. Pulmonary diagnosis of TGA (Transposition of the Great Arteries) was made. Patient had routine neurologic workup instituted. He was seen by neurology. He had complete recovery to baseline. He had MRI performed which revealed some small vessel ischemic changes only. Otherwise everything else was stable. Plan was to be discharged to home with follow-up by primary care physician as well as neurology as necessary. He is discharged in stable condition."

(i) The patient was not seen in triage until 14 minutes after arrival.

(ii) The triage nurse failed to assign the patient an ESI classification of at least a minimum of "2" per policy (Reference #4).

(iii) The triage nurse failed to, based upon the patient's presenting complaint, immediately notify the Clinical Supervisor/ Charge Nurse for STAT (immediate) placement which resulted in failure to activate the ED Stroke Alert Team and notification of the ED physician of the patient's arrival. (Reference #4). The physician did not examine the patient until 1 hour and 19 minutes after the patient arrived in the ED.

3. Review of the medical record of Patient #7 indicated that he/she presented to the facility ED on 8/12/17 at 4:07 PM with a complaint of trouble swallowing and an itchy throat. The patient left the facility without treatment on 8/12/17 at 4:47 PM - 40 minutes after initial presentation to the ED. The patient was not triaged in the 40 minutes spent at the ED. The facility was unable to provide evidence that a rapid triage function was initiated. Staff #4 agreed with these findings.

4. Review of the medical record of Patient #20 indicated that he/she presented to the facility ED on 12/29/17 at 5:24 PM with general complaints. The patient left the facility without treatment on 12/29/17 at 6:22 PM - 58 minutes after the initial presentation to the ED. The patient was not triaged in the 58 minutes spent in the ED. The facility was unable to provide evidence that a rapid triage function was initiated. Staff #4 agreed with these findings.











38289

38289

Based on medical record review, facility policy and procedure review, and staff interview, it was determined that the facility failed to provide a completed transfer form for patients transferring out of the emergency department (ED).

Findings include:

Reference #1: Facility policy titled, "Patient Transfer to another Facility," stated, "...Procedure: 6. Arrange appropriate transportation... 7. Complete Transfer materials: a. Universal Transfer Form Certification b. Physician Medical Necessity form... d. Prescriber Orders, To transfer patient to (name of facility), by ground/air transport with or without nurse and monitoring(note the type of monitoring)..."

Reference #2: Facility policy titled, "Emergency Medical Screening, Stabilizing Treatment and Transfer and On Call" stated, "... D. Process to Effectuate and "Appropriate Transfer" of an Individual Emergency Medical Condition... ___Medical Center shall ensure that all transfers are made using necessary equipment, including the use of necessary and medically appropriate life support measures during the transfer as well as a mode of transportation appropriate for the patient's condition, to affect the transfer safely....."

1. Review of Medical Record #3 revealed an incomplete "Transfer Certification" as indicated by the following:

a. "...7. Mode of Transport" section was missing the following items:

(i) "Additional Personnel needed"

(ii) "Service contacted:"

(iii) "By:"

(iv) "Time:"

(v) "ETA:)

b. "... 8 Patient Consent to Transfer" was not dated and was not signed by a witness.

2. Review of a TRANSFER CERTIFICATION form in the medical record of Patient #21 indicated that the "Name of the Destination Hospital" was not filled in. Also, the "Mode of Transportation" section included two entries, "helicopter" and "ALS Ambulance." The patient was not transferred by helicopter.

3. Staff #4 agreed that the transfer certification should be filled out in it's entirety before transport.