HospitalInspections.org

Based on review of facility Emergency Department (ED) records and staff interviews, the hospital failed to provide an appropriate and full medical screening examination within the capability of the hospital's emergency department for 1 of 22 (Patient #A) patient charts reviewed from May 2023 to December 2023.

Findings include:

In an interview with the Staff #2 on 01/09/2024 at 10:30 AM in the conference room, she stated that all ED records were paper charts. She stated that the nurse and provider would use the most appropriate emergency nursing and physician record form specific to the patient's chief complaints and all documentations were handwritten.

Review of the ED log from May 2023 to December 2023 revealed Patient #A presented to the ED on 11/01/2023 twice: 1:39 AM (Visit 1) and again at 8:30 PM (Visit 2).

Visit 1:
Review of Patient #A medical chart revealed he presented with chief complaint of "head pain, eye pain and swollen." Nurse (Staff #6) assessed Patient #A at 1:50 AM in Exam #2. Nurse (Staff #6) noted past medical history of HIV positive and colorectal surgery and chief complaints "Rt [right] eye pain; strep in nose; moaning; was at ER yesterday."

Nurse (Staff #6) obtained the following vital signs:
Systolic Blood Pressure : 127 mmHg
Diastolic Blood Pressure : 93 mmHg
Peripheral Pulse Rate : 62 bpm
Respiratory Rate : 18 BRMIN
SpO2 percent : 99 %
Temperature Oral : 98.0 DegF(Converted to: 36.1 DegC)
Pain : Yes, assessment required
Pain Assessment: 10/10
Primary Pain Location : Right Eye

Nurse (staff #6) noted the patient having taken Benadryl and Advil prior to arrival on 10/31/2023 at 11:30 PM . The triage nurse noted past medical history of HIV positive and colorectal surgery. Nursing assessment notes EENT as normal as well as skin and does not comment on the face at all.

MD (staff #3) assessed Patient #A at 02:00 AM with chief complaint of "facial pain" with onset within "3/4 days and worsen some yesterday"; on "augmentin for strep cellulitis of nasal passage." The physical exam included "R nasal muscosa edema and erythma." There is no documentation of an evaluation of the remained of the ENT area. There is no specific evaluation of the eyes other than a check mark for "eye nml [normal]" nor were there any notation of any rash to the face or nares.

Furthermore, the ROS (Review of Symptoms) section of the paper chart was blank apart for an "X" that marked "except as marked positive, all systems above reviewed are found negative."
No other documentation specific to the eyes, ENT or skin were available for review.

MD (staff #3) ordered labs, medication and CT scan "CBC [complete blood count], CMP [complete metabolic panel], Toradol 30 mg; Vancomycin; maxillofacial CT with IV contrast."

Review of the nursing notes indicated Patient #A was infused with vancomycin IV 1 gm/250 IVS from 03:00 AM to 05:35 AM. Patient was also given Tordal IV 30 mg with improved pain assessed at 3/10 at 03:08AM. Tylenol 1 gm PO given at 5:05 AM, with pain assessed at 4/10 at 5:35 AM.

Progress notes for MD (staff #3) at 03:00 AM indicated "maxillofacial CT neg" and diagnosis of facial cellulitis.

Nurse (Staff #6) made an additional note at 05:00 AM "pain coming back; doesn't have ride"; at 5:05 AM Staff #6 notes "tylenol given, vanc complete taken down; pt [patient] asleep throughout the whole process." Nurse (Staff #6) assessed pain at 5:35 AM with 4/10.

Patient was discharged home with medications for tylenol 1 gm PO.

Visit 2:
Review of Patient #A medical chart revealed he presented with chief complaint of "discharge coming out of forehead and swollen." Nurse (Staff #7) assessed Patient #A at 8:50 PM in Triage room. Nurse (Staff #7) noted past medical history of HIV positive and colon surgery and chief complaint of "facial cellulitis; seen and started on treatment last night/this am (discharged at 07:00 this morning)."

Nurse (Staff #7) obtained the following vital signs:
Systolic Blood Pressure : 130 mmHg
Diastolic Blood Pressure : 72 mmHg
Peripheral Pulse Rate : 89 bpm
Respiratory Rate : 16 BRMIN
SpO2 percent : 98 %
Temperature : 98.0 DegF(Converted to: 36.1 DegC)
Pain : Yes, assessment required
Pain Assessment: 7/10

Nurse (staff #7) also noted "pt noted to have some mild redness and swelling above the R [right] eye and forehead and minimal amount of clear drainage." The rest of the paper chart indicated that physical assessment is otherwise normal with normal checked for the remaining assessment.

MD (staff #5) assessed Patient #A at 9:10 PM in the triage room and noted "39 yo [year old] M [male] HIV+ facial cellulitis seen yest [yesterday] this ER for same, given Rx d/c this AM (14 [hours] ago) returns."

Furthermore, the ROS (Review of Symptoms) section of the paper chart was blank apart for backslash [negative] on "recent illness"; "fever"; "swollen glands"; "fainting"; "dizziness"; and "weakness" and an "X" that marked "except as marked positive, all systems above reviewed are found negative."
No other documentation specific to the eyes, ENT or skin were available for review.

No documentation was provided for the facial, EENT [eye, ear, nose, and throat] or skin physical exam.

Furthermore, progress notes included "maxillofacial CT; vanco yest; VSS [vital signs stable] afrebrile; WBC [white blood count] 5.9 WNL [within normal limits] CBC [complete blood count] CMP [complete metabolic panel] WNL."

Diagnosis noted as "facial cellulitis."

Patient was discharged home with no other interventions done.

An interview with Staff #3 on 01/09/2024 at 1:25 PM in the administration conference room and after review of Patient #A ED (visit 2) chart, he confirmed that the medical screen were incomplete. He stated that there should have been assessment of the eye and the discharge that was noted by the nurse.