HospitalInspections.org

Based on interview and review of policies and records, it was determined the hospital failed to ensure a medical record was maintained for 1 of 11 patients (#11) whose records were requested. This failure resulted in a lack of clarity as to the course of treatment during the hospital stay. Findings include:

The policy "EMERGENCY ROOM ADMISSION," approved 3/22/11, stated "An ER record will be completed on any person presenting to the emergency room requesting treatment." The hospital did not complete a medical record in accordance with policy as follows:

On 10/07/13 at 2:10 PM, surveyors requested the medical record of Patient #11 after finding documentation in a grievance log of an altercation between an ER physician and Patient #11's family. The CFO and QM stated Patient #11, an 18 year old male, had come to the ER just before midnight on 6/15/13, with his family for treatment of a wrist injury. The QM stated before the ER RN could register him, Patient #11's family had an altercation with the physician and left to go to another hospital. She stated ER staff did not even have Patient #11's full name at the time he left the ER. She stated because Patient #11 was not registered, there was no medical record corresponding to the ER visit. The QM and CFO also confirmed there was no medical record for Patient #11 or documentation of Patient #11 in the ER log. The QM stated she obtained written statements from staff and the physician documenting the incident.

A statement dated 6/16/13, and signed by an RN, documented Patient #11 and his family arrived to the ER waiting room on 6/15/13 at approximately 11:45 PM. She documented Patient #11's mother stated the he had been stabbed at a park but had been treated by EMS on-site and was now presenting to the ER to have a wrist injury evaluated. The RN documented she brought Patient #11 and family to an exam room and Patient #11 removed a dressing placed by EMS staff to reveal his right wrist was visibly swollen. The RN documented she placed the Patient #11's arm on a pillow, placed a blood pressure cuff and pulse oximeter, and pressed the start button to obtain vital signs. She stated Patient #11's mother was taking pictures of her son's wrist.

The RN documented that at this time, the ER physician came into the exam room. She documented Patient #11's mother had moved to the foot of the bed and continued to point her cell phone in a manner as if to take a photo or record a video. She documented the mother pointed her phone in the direction of the physician as he was listening to Patient #11's heart and lungs with a stethoscope. The RN documented the physician told the mother that she could not take pictures or use her cell phone in the ER. The RN went on to document an argument ensued over the use of the cell phone which resulted in Patient #11 and his family leaving the ER shortly after. There was no documentation to indicate what time Patient #11 and his family left the ER.

A statement written by the ER physician on 6/16/13 at 11:50 AM documented Patient #11 arrived to the exam room on 6/15/13 at about 11:50 PM and upon entering the patient's room, the physician examined a wound to Patient #11's chest and documented a "1/4 (inch) stab wound on the (left) breast 1/4 (inch) deep" with no active bleeding. He documented Patient #11 was breathing and conscious, in no acute distress. He documented he did a full chest and abdomen examination but before he could examine the Patient #11's wrist, he saw that he was being filmed or photographed by Patient #11's mother on her cell phone. The physician documented an argument ensued between himself and Patient #11's parents over the use of the cell phone, during which time the physician informed the family 'they could go to any ER...." The physician documented Patient #11 and family left shortly after this exchange, and Patient #11 was in no acute distress. There was no documentation to indicate what time Patient #11 and his family left the ER.

The CNO was interviewed on 10/08/13 at 9:10 AM. He stated after midnight, there were no admission staff present in the ER so the RNs would do a "quick reg (register)," which involved entering the patient's name, date of birth, and physician name in the computer system. The RN would also make a copy of the patient's drivers license and insurance card and and have the patient sign admission paperwork, including the consent for treatment. This process created a medical record and entered the patient in the ER log. The CNO confirmed nursing staff did not complete a "quick reg" on Patient #11 before he and his family left the ER. He confirmed there was no medical record for Patient #11 documenting the events detailed in the staff and physician statements described above. He confirmed that without an entry in the ER log or medical record documentation, the course of events related to Patient #11's ER visit were unclear.

The hospital did not maintain a record documenting Patient #11's ER visit.