HospitalInspections.org

On 3/19/2017 at approximately 7:00 PM, a police officer (staff E) drove a twenty-five year old male (patient #1) to Hospital B for treatment of a behavioral health condition. On the way to Hospital B the police officer came to the emergency department of Hospital A and requested first aid treatment for patient #1. Patient #1 had fallen and sustained abrasions to the right arm while walking from his residence to the police car. At Hospital A, a registered nurse (Staff A) cleaned and applied a sterile dressing to patient #1's right arm, and the patient left the emergency department in custody of the police. Based on interview and record review deficiencies are cited in the care of this patient as follows:

During a telephone interview conducted on 3/30/2017 at approximately 1:45 PM the police officer (Staff E) stated that he brought patient #1 to the emergency department of Hospital A. He requested treatment for abrasions on the patient's right arm. An emergency department nurse (Staff A) at Hospital A, cleaned and dressed the wounds on the patient's right arm. Based on a security video reviewed by survey staff on 3/28/2017, patient #1 arrived at Hospital A with the police on 3/19/17 at 7:09 PM and left the hospital with police at 7:19 PM.

During survey on 3/28/17 at noon, survey staff reviewed the emergency department log for the date of 3/19/2017 and found no record for the presence of patient #1 at the hospital.

During the entrance conference at Hospital A on 3/28/2017 at 10:00 AM, the hospital's Director of Quality and Risk Management (Staff M) confirmed that there was no medical record created for the date of service 3/19/2017 for patient #1. Emergency department staff did not record a nursing assessment or document the nursing care provided to patient #1.

The ED RN (Staff A) confirmed on interview on 3/29/2017 at 12:30 PM, that patient #1 was not offered a Medical Screening Exam during his visit to the ED on 3/19/2017.