HospitalInspections.org

Based on observation and review of 10 out of 10 Emergency Department(ED) patient medical records and interview of the ED staff, it was determined that the ED Nursing Staff failed to consistently query, assess, and document incoming ED patients ' Advanced Directive status.
The findings were:
The hospital ' s electronic patient medical records system has an Adult ED Index Window within the admission nursing assessment used in the ED for incoming patients. A block on the assessment window was designated as the "Advanced Directive/Health Care Decisions" and had a radio button for completion. Interview of the ED Nursing Staff as to how staff use this block was explained that when the radio button is blackened, that indicated that the patient was asked by the nursing staff about if they had Advanced Directives.
Further interview of the ED staff revealed that the Advanced Directive block lacked a drop down box for nursing staff to enter key information such as: whether the patient had an Advanced Directive, if the patient did not have an Advanced Directive or other document such as a MOLST and did not provide it, or that the patient was afforded an opportunity to receive information about Advanced Directives or to develop an Advanced Directive with the outcome.
Failure by the ED Nursing Staff to query incoming ED patients about their Advanced Directive Status potentially placed patients at risk for not having their wishes honored or receiving care that might be determined inappropriate.

Based on review of the medical record of patient#5, it was determined that the hospital failed to document an order for medication to sedate the patient in order to complete emergent testing.

Patient #5 walked into the Emergency Department confused with large forehead hematoma. The review of a nursing progress note dated 4/27/15 at 7:24am revealed the patient was intubated and paralyzed in order to complete a head CT scan. The note documented the medication used to paralyze the patient and the patient tolerated the procedure. Patient #5 was extubated and awake but confused. Review of the orders revealed no order for the medication. The hospital failed to provide an electronic order for medications used to paralyze a patient prior to emergent testing. The only indication of the medication use was found in a nursing note.