HospitalInspections.org

Based on document review and interview it was determined that 1 of 2 (E#4) emergency department nurses, the Hospital failed to ensure a Registered Nurse (RN) evaluated the nursing care for each patient.

Findings include:

1. The Hospital's policy titled, "Assessment & Reassessment of Patients in the Emergency Department (8/2018)" was reviewed on 4/15/2021 and required, "Reassessment documentation is done on all patients receiving an intervention ... or change in condition. Reassessment includes ... specific attention to the area and focused assessment of chief complaint the patient was brought to the ED for. Reassessment schedule: ... upon discharge. ... Patient assessment is the responsibility of the Registered Nurse."

2. The clinical record of Pt. #1 was reviewed on 4/14/2021. Pt. #1 presented to the emergency department (ED) on 2/3/2021 at 3:57 AM with complaints of a laceration to the forehead following an MVC (motor vehicle collision).

A clinical assessment was performed by the ED RN (E#4) at 7:49 AM that included only vital signs and a pain assessment. The documentation lacked a reassessment with specific attention to the chief complaint. Pt. #1 was discharged at 1:11 PM, and Pt #1's clinical record also lacked a reassessment by the RN upon discharge.

3. The Nurse (E#4), who cared for Pt. #1, was interviewed on 4/14/2021 at 12:20 PM. E#4 stated that he thought he documented his assessment and readiness for discharge in [Pt. #1's] clinical record but could not find anything.

4. The ED Nurse Manager (E#5) was interviewed on 4/14/2021 at 12:35 PM. E#5 stated that she reviewed the record and did not see a reassessment performed by E#4. E#5 stated, "[Pt. #1] needed to be assessed for ability to be discharged that included behavior and ambulation."

Based on document review and interview it was determined that for 1 of 2 (MD#1) Emergency Department Physicians, the Hospital failed to ensure policies and procedures governing medical care provided in the emergency department were followed.

Findings include:

1. The Hospital's policy titled, "Assessment & Reassessment of Patients in the Emergency Department (8/20218)" was reviewed on 4/15/2021 and required, "Medical Staff: ... Regular progress notes including assessments and a description of the patient's response to treatment shall be written as the case indicates."

2. The clinical record of Pt. #1 was reviewed on 4/14/2021. Pt. #1 presented to the emergency department (ED) on 2/3/2021 at 3:57 AM with complaints of a laceration to the forehead following an MVC (motor vehicle collision).

The medical screening exam by the ED Physician (MD#3), dated 2/3/2021 at 4:38 AM, included, "Will continue to monitor until clinically sober. Signed out to [another physician- MD#1] with plan to reassess once sober. If tertiary [high level review]survey ok, patient able to ambulate and tolerate fluids, and has no additional complaints, can potentially discharge home."

The nurse's discharge summary (E#4), dated 2/3/2021 at 1:11 PM, included that Pt. #1 was discharged via public transportation to home.

3. The clinical record lacked documentation of an assessment completed by the physician (MD#1) who took over the care of Pt. #1 on 2/3/2021 at 7:00 AM.

4. The Medical Director of the Emergency Department (MD#2) was interviewed on 4/15/2021 at 11:20 PM. MD#2 stated, "It was a physician error. There should have been an addendum note with a reassessment. Otherwise, how do we know that the patient was ready for discharge."