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3400 MINISTRY PARKWAY

WESTON, WI 54476

COMPLIANCE WITH 489.24

Tag No.: A2400

Based on interviews and record reviews, staff at this facility failed to comply with the EMTALA regulations found at CFR 489.24 by not completing full vital signs on patients under 5 years of age who presented for treatment at the emergency department for 4 of 18 medical records reviewed out of a total of 25 medical records reviewed (Pt. #4, 23, 24 and 25).

Findings include:

1. The Emergency Department staff failed to obtain blood pressure measurements on children under 5 years of age. See A-2406.


The cumulative effects of these failures has the potential to affect all children who present for emergency services.

MEDICAL SCREENING EXAM

Tag No.: A2406

Based on record review and interview, Emergency Department staff at this facility failed to complete a comprehensive medical screening examination that included blood pressure measurement in 4 of 18 children under the age of 5, out of 25 medical records reviewed (Pt. #4, 23, 24 and 25).

Findings include:

The facility's policy titled, "Emergency Department Protocols," #24740 which has a revision date of 9/29/15, was reviewed on 11/23/2015 at 11:00 AM. The policy states in part (on page 1 of 15), "Vital Signs Standard, All patients will have a baseline set of vital signs on admission (including pediatric patient less than 5 years of age.)"

The facility's policy titled, "Pediatric Emergencies," #22748 which has a revision date of 9/29/2015, was reviewed on 11/23/2015 at 11:10 AM. The policy states in part (on page 2 of 5), "Secondary Assessment: ...2. Obtain full set of vital signs on all pediatric patients, and following interventions such as IM [intramuscular] or IV [intravenous] pain medication, and/or at discharge. (Vital signs include: blood pressure, heart rate, respiratory rate, temperature & [and] O2 [oxygen] saturation."

In an interview with Emergency Department Director B on 11/23/2015 at 11:15 AM, Director B stated that Emergency Department staff received education regarding policy changes for pediatric vital signs. This education was completed in the form of an email dated September 29, 2015 from Registered Nurse C (in the director's absence), and stated, "...3) Pediatric Vital Signs: ALL pediatric patients will require at least one full set of vital signs: Temp [temperature], RR [respiratory rate], HR [heart rate], O2 Sat [oxygen saturation], and Blood pressure. This has to be documented in all pediatric patients. THIS EFFECTIVE IMMEDIATELY. ALL PEDS [pediatric] PATIENTS MUST HAVE 1 B/P [blood pressure] DOCUMENTED."

The facility's Medical Record audit data for October and November, completed by Emergency Department Director B, was initially reviewed at 11:21 AM on 11/23/2015 and then referred to throughout the day.

Per interview with Quality Specialist A on 11/23/2015 at 11:21 AM, Quality Specialist A stated that there is no medical record audit data from the quality department at this time.

Patient #4's medical record revealed that Patient #4, age 18 months, arrived at the Emergency Department on 10/24/2015 at 11:53 AM with complaints of cough and shortness of breath. Nurse ' s Notes documentation states at 12:05 PM " Patient is alert and oriented, behavior appropriate for age ...Patient appears to be crying. " At 1:40 PM " Patient appears quiet. " Patient #4 was transferred from the facility at 1:58 PM to a higher level of care.

Pulse, respirations, oxygen saturation and weight were taken at 12:05 PM.
Temperature was taken at 12:16 PM.
Pulse, respirations and oxygen saturation were taken at 1:32 PM.
Pulse, respirations and oxygen saturation were taken at 1:42 PM.
Pulse, temperature and oxygen saturation were taken at 1:46 PM.

No blood pressure was taken/recorded as part of the medical screening examination.

The above findings were confirmed per interview with Director B on 11/23/2015 at 11:40 AM. Director B stated, " The nurse should be documenting why the blood pressure isn ' t recorded in the medical record. Patient #4's medical record documentation was reviewed in October by Emergency Department Director B as part of the appropriate documentation audit. The results of this audit indicate that there was no blood pressure documented.

Per interview with Director B on 11/23/2015 at 12:15 PM regarding the lack of blood pressures found in the completed audits, Director B stated, "In October I approached staff verbally and asked them to go back and indicate why no blood pressure was documented but in November I started to write down the action I took and put it in writing."

Patient #23's medical record revealed that Patient #23, a 17 month old, presented to the facility's Emergency Department on 11/17/2015 at 8:33 PM with complaints of cough, congestion and feeling hot. Nurse's notes documentation indicates Patient #23 was, "Alert and oriented, behavior appropriate for age." Patient #23 left the facility at 10:01 PM.

Pulse, respirations, temperature, oxygen saturation and weight were taken at 8:48 PM.
Pulse, respirations, and oxygen saturation were taken at 9:59 PM.

No blood pressure was taken/recorded as part of the medical screening examination. This finding was confirmed per interview with Quality Specialist A on 11/23/2015 at 2:20 PM. Quality Specialist A stated, "No, there is no documentation."

Patient #23's medical record documentation was reviewed by the Emergency Department Director B in November for appropriate documentation. The results of this audit indicate that there was no blood pressure documented and Director B's follow up comments are, "Email sent to both nurses about missing BP [blood pressure] and requesting an addendum to be added if able to remember reason for not obtaining the BP." There was no addendum added to Patient #23's documentation.

Patient #24, age 2 years, received Emergency Department services at the facility on 11/7/2015 from 7:12 PM to 7:56 PM for an infected foot laceration. Nurse ' s Notes documentation states at 7:30 PM " Patient is alert and behavior is appropriate for age ...Behavior is agitated, uncooperative. "

Vital signs (pulse, respirations, temperature and weight) were taken at 7:27 PM.

No blood pressure was taken/recorded as part of the medical screening examination.

Patient #25, age 18 months, received Emergency Department services at the facility on 11/8/2015 from 9:23 AM to 10:07 AM with complaints of diarrhea. Nurse ' s Notes documentation states at 9:32 AM, " Patient is alert ...Behavior is appropriate for age, cooperative. "

Temperature and weight were taken at 9:32 AM.
Pulse, respirations and oxygen saturation were taken at 9:36 AM.

No blood pressure was taken/recorded as part of the medical screening examination.

The findings for Patient #24 and Patient #25's medical records were confirmed per interview with Director B at the time of review on 11/23/2015 at 2:30 PM.

Patient #24 and 25's medical record documentation was reviewed by Emergency Department Director B as part of the appropriate documentation audit in November. The results of this audit indicate that there was no blood pressure documented and Director B's follow up comments for both patients are, "Email sent to nurse about missing BP [blood pressure] and requesting an addendum to be added if able to remember reason for not obtaining the BP." There was no addendum added to Patient #24 or 25's documentation.