HospitalInspections.org

Based on observation, record review and interview it was determined that the hospital failed to maintain an effective grievance process for one Emergency Room patient by failing to document in-servicing to the staff for all identified concerns during care. (Patient identifier is #1.)

Findings include:

Tour of the Emergency Room (ER) on 7/2/12, with Staff E (Director Emergency Nursing and EMS) at approximately 1:00 p.m. revealed the following observations, the Emergency Room ambulance entrance has a set of full glass automated doors which lead from the ambulance entrance and emergency room parking lot. This set of doors opens to an ER hallway directly to ER Room 4 which contains two bays for patient care. Each bay has curtains which can be pulled to allowed privacy during care. ER Room 4 has a set of full view sliding glass doors which open to this hallway directly from the ER ambulance entrance.

Further observation revealed that an individual in the ER parking lot could see directly into the ER and into ER Room 4. Staff E confirmed this finding at the time of the Emergency Room observation tour and was aware that ER Room 4 was visible from the ER parking lot, ambulance entrance, unless the curtains was pulled during care.

Record review on 7/2/12 of the Emergency Room notes for Patient #1 dated "04/23/2012" revealed the following, "1835 Daughter to desk, tearful she stepped out for a minute and on return found patient had removed his IV (intravenous), taken off monitor leads, urinated on floor and removed all clothing. Pt (patient) very confused, assisted back to bed... 1855 22g to left AC (antecubital), pt placed back on monitor and O2 (oxygen)."

Review of the hospital "PATIENT RELATIONS WORKSHEET" dated "5/1/2012", written by Staff B, (Risk Management), revealed the following;
"Just wanted to let you know I received a call from ... in regards to a patient complaint. Daughter of patient [Patient#1]... called upset about her father's care in the Emergency Department. He was brought in from the ... Home with a fever and agitation. ...(physician name) had informed her that he was going to be admitted and encouraged her to step out and get something to eat. The primary nurse was not aware that the daughter left as she had been at the bedside with him since his arrival. Upon arrival back to the ER she could see her father through the ambulance doors and he was unclothed and had pulled his IV out. She expresses this was poor care...".

Review of another letter signed by Staff B addressed to the daughter of Patient #1 dated "May 1, 2012" showed the following:
"I was recently made aware of an incident involving your father (Patient #1), which occurred while he was in our Emergency Room awaiting admission on April 23, 2012. It's my understanding that we failed to pass along information that you were leaving his bedside; and that this resulted in inadequate monitoring. While there was no untoward outcome or injury to your dad, we should have done better...I understand that following your meeting with Staff D, Clinical Coordinator of our Emergency Department, your experience was discussed at a departmental meeting; and all staff were reminded of the importance of "hand-off communications," especially when patient safety is involved....I am very sorry for not monitoring ...(Patient #1) more closely once you left the Emergency Department..."

During interview with Staff D and Staff E (Director of Emergency Nursing and (EMS)) on 7/2/12 at approximately 1:50 p.m. Staff D and E confirmed that Patient #1 was left unattended, had urinated on the floor, was unclothed and had removed the IV himself on the April 23, 2012 visit to the Emergency Room.

During interview with Staff F (V.P. Patient Care Services) and Staff G (Patient Safety/Risk Management) on 7/2/12 at approximately 2:10 p.m. it was confirmed that there is no documented evidence from the Emergency Department of a staff meeting or staff in-service
regarding the incident listed above for Patient #1 on April 23, 2012.

Cross reference #0143.

Based on observation, record review and interview it was determined that the hospital failed to ensure the personal privacy for one emergency room patient. (Patient identifier is #1.)

Findings include:

Tour of the Emergency Room (ER) on 7/2/12, with Staff E (Director Emergency Nursing and EMS) at approximately 1:00 p.m. revealed the following observations, the Emergency Room ambulance entrance has a set of full glass automated doors which lead from the ambulance entrance and emergency room parking lot. This set of doors opens to an ER hallway directly to ER Room 4 which contains two bays for patient care. Each bay has curtains which can be pulled to allowed privacy during care. ER Room 4 has a set of full view sliding glass doors which open to this hallway directly from the ER ambulance entrance.

Further observation revealed that an individual in the ER parking lot could see directly into the ER and into ER Room 4. Staff E confirmed this finding at the time of the Emergency Room observation tour and was aware that ER Room 4 was visible from the ER parking lot, ambulance entrance, unless the curtains was pulled during care.

Record review on 7/2/12 of the Emergency Room notes for Patient #1 dated "04/23/2012" revealed the following; "1835 Daughter to desk, tearful she stepped out for a minute and on return found patient had removed his IV (intravenous), taken off monitor leads, urinated on floor and removed all clothing. Pt (patient) very confused, assisted back to bed... 1855 22g to left AC (antecubital), pt placed back on monitor and O2 (oxygen)."

Review of the hospital "PATIENT RELATIONS WORKSHEET" dated "5/1/2012", written by Staff B, (Risk Management), revealed the following;
"Just wanted to let you know I received a call from ... in regards to a patient complaint. Daughter of patient [Patient#1]... called upset about her father's care in the Emergency Department. He was brought in from the ... Home with a fever and agitation. ...(physician name) had informed her that he was going to be admitted and encouraged her to step out and get something to eat. The primary nurse was not aware that the daughter left as she had been at the bedside with him since his arrival. Upon arrival back to the ER she could see her father through the ambulance doors and he was unclothed and had pulled his IV out. She expresses this was poor care...".

Review of another letter signed by Staff B addressed to the daughter of Patient #1 dated "May 1, 2012" showed the following;
"I was recently made aware of an incident involving your father (Patient #1), which occurred while he was in our Emergency Room awaiting admission on April 23, 2012. It's my understanding that we failed to pass along information that you were leaving his bedside; and that this resulted in inadequate monitoring. While there was no untoward outcome or injury to your dad, we should have done better...
I understand that following your meeting with Staff D, Clinical Coordinator of our Emergency Department, your experience was discussed at a departmental meeting; and all staff were reminded of the importance of "hand-off communications," especially when patient safety is involved....I am very sorry for not monitoring ...(Patient #1) more closely once you left the Emergency Department..."

During interview with Staff D and Staff E (Director of Emergency Nursing and (EMS)) on 7/2/12 at approximately 1:50 p.m. Staff D and E confirmed that Patient #1 was left unattended, had urinated on the floor, was unclothed and had removed the IV himself on the April 23, 2012 visit to the Emergency Room.