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The hospital failed to maintain an accurate and current medical record for inpatients and out patients that were evaluated or treated in the hospital. Clinical records were not readily accessible to staff if the entry was not signed by the author for 25 of 60 medical records; Laboratory and medication orders were incomplete for 1,701 patient visits of 12,910 visits; and Emergency department documentation was incomplete for 2 of 2 patients (# 22 and #23) receiving cardiopulmonary resuscitation and for 1 patient (#11) receiving IV fluids. The findings included:
The inaccurate and incomplete medical records had the potential to limit the ability to provide quality care to patients. Cross refer to A438.

Based on record review the hospital failed to admisiter medication per physican orders for 2 patients(#5 and #24) seen in the emergency department. The findings include:


1. Patient #5 presented to the ED on 8/31/10 at 2235 (11:35 PM) with complaints of altered mental status.

a. The QMP ordered Zofran 8 mg IV, GI cocktail, and Zantac 50 mg. Review of the medication administration section of the nursing ED record showed the nurse had documented giving only 4 mg of Zofran, which would be a medication administration error. Verification with pharmacy records showed the nurse had only withdrawn 4 mg of the Zofran for administration.

b. Patient #5 returned to the ED on 9/1/10 at 1825 (6:25 PM) with complaints of altered mental status. The QMP ordered Ativan 1 mg IV and Zantac 50 mg. Review of the medication administration section of the nursing ED record showed the nurse had documented giving Zantac 150 mg. Verification with pharmacy records showed the nurse had only withdrawn 50 mg of the Zantac for administration (documentation error).

2. Per the ED log patient #24 presented to the ED on 9/11/10 at 1616 (4:16 PM) with complaints of a possible kidney stone. The ED log indicated the patient was transferred to another area hospital per private auto.

a. At the time of the surveyor's review of the record on 9/21/10 the patient's record revealed no documentation of this 9/11/10 ED visit including evidence the nursing staff triaged or assessed the patient, evidence a MSE had been conducted by a QMP or evidence the patient received any stabilizing treatment or care for the "kidney stones". Subsequent documentation was received from the hospital on 10/5/10.

b. This subsequent documentation showed a QMP order for Levaquin (600 mg ?) IV. There was no evidence this medication had been given.

Based on record review and interview the ED (emergency department) staff failed to promptly assess and record the pain of a resident who arrived at the ED and complained of pain. In addition, the facility ED staff failed to give a patient's family discharge instructions and record that in the clinical record The findings include:

1. On 8/3010 at 5:10 PM patient #25 arrived at the ED and complained of pain in her left lower quadrant. The patient complained of painful urination and a recent lack of energy. The patient had a kidney transplant in 1995. The clinical record showed that she arrived at the ED at 5:10 PM; was checked in the waiting room area at 6:30 PM; was assessed for pain at 7:45 PM. The 7:45 PM assessment recorded pain at the maximum level (10 out of 10) and she was given 650 milligrams of Tylenol. The patient was sent to the X-ray department at 8:00 PM . At 10:53 PM the resident was given a Vicodin (a narcotic pain medication) for pain which was assessed at 10 out of 10. The resident was admitted to the hospital and transferred to acute care nursing at 11:35 PM.
The clinical record did not have an assessment of pain from 5:10 PM until 7:45 PM and no assessment of the effect of the Tylenol after it was given. The next pain assessment was at 10:53 PM and no assessment of the affect of the Vicodin was done.
The record showed 2 pain assessments during the 6 hours the resident was in the ED. Each time the resident was experiencing maximum pain (10 out of 10) and the affect of pain medication was not assessed after 30 - 60 minutes.
On 9 20/10 at 4 PM the nursing supervisor of the ED was interviewed and she stated that pain assessments done in the ED would be part of the clinical record and would be recorded, if done.
2. On 9/2/10 at 7:25 PM patient #12, a seven month old infant, arrived at the facility ED. He had fallen from his stroller and down concrete stairs. He was seen at 7:45 PM and discharged at 8 PM.
The clinical record showed the patient was treated for "CHI" (closed head injury) and the physician wanted to check the patients facial bone the next week .The plan called for "CHI precautions" and the ED physician ordered Decadron (a medication to decrease brain swelling due to trauma).
On 9 20/10 at 4 PM the nursing supervisor of the ED (staff T) was interviewed and she stated that discharge planning done in the ED would be part of the clinical record, if done. She could locate no record of discharge planning regarding CHI precautions.
There is no record that the patient's mother was given instructions about CHI (closed head injury) precautions. The closed head injury precautions would educate the mother to potential problems. The symptoms of a closed head injury might take time to appear and failure to recognize the symptoms could cause a fatal delay in treatment.