HospitalInspections.org

Based on document review and interview, the facility fails to maintain a complete central log on all patients presenting to the emergency department..

Findings:

Review of the facility's computerized central emergency department log from 12/09 to 6/10/10 revealed that not all patients' disposition status is listed. For example, on May 3, 2010, the log demonstrated that of the 53 presenting patients, 9 lacked a disposition entry as well as the date and time it occurred.

This was confirmed on interview with the ED Medical Director and interim ED Nurse Manager on 6/10 at 0930.

Based on medical record review and interview, the facility failed to stabilize a patient prior to discharge.

Findings:

On 3/21/10 a 21 year-old gravida 3 para 2 patient presented, via ambulance, to the facility. The full term patient's (38.3 weeks gestation) membranes had spontaneously ruptured at home and she was experiencing mild contractions every 3 to 4 minutes. The patient indicated that she wanted to deliver at another hospital so the physician discharged her. There was no documented evidence in the medical record to indicate that the patient was informed of the consequences of her decision. The facility's document "Informed Consent to Transfer and Physician Certification of Transfer" was not in the patient's medical record indicating her written request to go to another hospital, knowledge of the risks and benefits of going by car and refusal to stay at St. Mary's to deliver the baby.
In addition, the hospital failed to effect an appropriate transfer as they failed to contact the other facility to determine if the receiving facility had the capability and capacity to care for the patient and agreed to accept the patient.

This was confirmed on interview with the involved nurse on 6/10/10 at 0930 and the involved obstetrician on 6/15/10 at 0900.