HospitalInspections.org

Based on record review, observation, and interview the facility failed to ensure medical records were accurately written in one of 20 records reviewed (Patient #1) when the medical record reflected that Patient #1 could ambulate but was never evaluated for mobility.
.
The Findings were as follows:
.
Client Record Review:
1. The treating provider, Staff #5, documented on 04/08/2023 at 1:55 PM during the medical screening exam (MSE) that Patient #1 had "normal range of motion of all 4 extremities" and was "able to ambulate".
.
2. Staff #5 stated in the discharge notes on 04/08/2023 at 4:46 PM that Patient #1 was not able to ambulate.
.
Observation:
3. A tour of the Emergency Department (ED) on 10/04/2023 at approximately 11:45 AM revealed that the facility had two of the 22 patient care rooms in the ED on the adult side that were dedicated as 'Fast-Track' rooms (which are utilized by the facility for patients needing "lesser" treatment and contained a recliner or chair rather than a bed).
.
Interviews:
4. On October 3, 2023, at 1430, the Fast Track RN for the facility (Staff #9) was interviewed.
.
5. Staff #9 stated that when (Patient #1) was unable to stand, that is when they (Staff #5 and Staff #9) were discussing admitting her." It was confirmed through interviews that Patient #1 was never placed in a bed but was in the "Fast-Track" area or in the patient's waiting room for the entirety of her visit outside of going to radiology for her CT scans. This is where Patient #1 was assessed by Staff #5, the facility's ED Provider (in her wheelchair). There was no bed in which Staff #5 could have placed Patient #1 in order to complete the assessment for range of motion.
.
6. On the afternoon of 10/03/2023, at 2:10 PM the treating ED provider (Staff #5) was interviewed.
Staff #5 was asked if she knew why Patient #1 was not placed in an ED bed.
Staff #5 replied that there was a very long wait that day and that nurses are responsible for bed placement, and she (Staff #5) thought we (the facility) must be very full for her (Patient #1) to have not been placed into a bed.
.
7. On 10/03/ 2023, at 11:20 AM, one of the facility's ED physicians (Staff #8) was interviewed.
Staff #8 was asked if it would it be common to keep a patient who is verbalizing extreme pain and inability to ambulate on the "fast track" side of the ED as opposed to being monitored in the ED.
Staff #8 replied that when we evaluate patients that do not seem to fit the pattern, we try our best to communicate to meet their needs. If they cannot ambulate effectively, the staff may try to find ways to accommodate their needs. On the string of trauma, if someone can bear weight then that patient may not need evaluation in an ED bed setting. The goal is to evaluate any patient on a stretcher and in a private space to complete a thorough and complete eval. When a patient does not fit the expected ED course, the provider will notify nursing colleagues to explore other avenues for the patient. In the case where a patient is not ambulating well, at that point, you would discuss the next steps with the patient, which may include further imaging.
.