HospitalInspections.org

Based on interview and record review the facility failed to ensure 3 of 3 patients presenting to the Emergency Department (ED) had complete assessments and physician orders (Patient #s' 2, 4, and 5).
This deficient practice had the likelihood to cause harm in all patients presenting to the Emergency Department.
Findings include:

Review of ED notes revealed Patient #4 was a 21 year old female who presented on 02/09/2015 at 10:31 p.m. with flank pain (possible kidney stones). Review of the nursing triage report revealed Patient #4 had a pain level of 8 out of 10 (0 indicating no pain and 10 severe pain).
Review of the physician's medical screen revealed Patient #4 was seen at 10:20 p.m. (9 minutes before presentation). The time was inaccurate.
Review of physician orders revealed an area for staff to document when the physician/provider was notified (of the patient presenting). The area was left blank. There were orders written for the pain medication "Toradol 30 IVP". The order did not include the milligrams or the frequency. There was also an order for intravenous fluids which was documented "NS". There was no documentation of what strength of normal saline or the rate.
Review of the ED record revealed Patient #4 was discharged at 01:22 a.m. (2/10/2015).
There was no documentation of when the pain medication was administered or the intravenous fluids started. There was no documentation of the pain level decreasing prior to discharge nor assessment of what it was on discharge.

Review of ED notes revealed Patient #2 was an 11 year old male who presented on 02/10/2015 at 12:03 midnight with joint swelling. Review of the nursing triage report revealed Patient #2 had a pain level of 6 out of 10 (0 indicating no pain and 10 severe pain).
Review of physician orders revealed an area for staff to document when the physician/provider was notified (of the patient presenting). The area was left blank. The orders were not signed off or timed by the physician. One side of the order page included an area for physician orders to be written, but it was left blank. Evidence was found on the chart showing lab being drawn and an x-ray being performed while Patient #2 was at the hospital.
Review of a discharge summary dated 02/10/2015 at 0045 revealed Patient #2 had a sprained finger. There was no documentation of a nursing assessment of how the finger looked on discharge nor the patient's pain level prior to discharge.


Review of ED notes revealed Patient #5 was a 66 year old male who presented on 02/10/2015 at 1:36 a.m. with chest pain.
Review of a nursing Chest pain protocol revealed it was implemented, but nursing failed to document the time of provider was notified and the time the protocol was implemented.
Review of the physician's medical screen revealed Patient #5 was seen at 0200 a.m.

During an interview on 02/11/2015 after 9:30 a.m., Staff #2 confirmed the missing information.

Review of a facility policy named "Clinical Documentation Guidelines" dated 01/ 22/2015 revealed some of the following instructions:

The medical record serves the following purpose:
1. Provide an efficient system of data collection to demonstrate assessment of
patient needs, planning of the course of treatment, and as a communication
tool among caregivers;
2. Provide a chronicle of the patient ' s clinical course of care, response to previous care and the current status;
3. Document information that will lead to evaluation of care rendered and the patient ' s progress in achieving outcomes;
4. Facilitate continuity of care;
5. Demonstrate patient progress towards a more optimal health status

Members of the clinical care team are each responsible and accountable for documenting their plan for the delivery of care, the care they provided, and the patient's response to such care. Team members will evaluate, re-evaluate, and alter or maintain care based on the hands-on clinical response of planned care of patient outcomes in an ongoing effort to achieve optimal patient health status. This documentation is to be a dynamic and ongoing record of the patient ' s progress.

Documentation of Care is organized in categories as noted below:
· Patient assessment, medical plan, and direction for care delivery (i.e., orders) are provided by the Physicians involved in the care of the patient. The Physicians provide a History and Physical upon admission, Specialty Consultations, Orders for care to be provided, and Progress Notes which contain the most up to date medical evaluation. The specific requirements for documentation by the members of the medical staff are found in the Medical Staff Bylaws and Rules and Regulations.
· Patient assessment and nursing plan of care are provided by the licensed nurse assigned to the patient upon admission to the hospital. Patient reassessments are to be conducted with each new shift change, change to the patient condition, or under the direction of the Physician. Any changes to the plan of care should be noted at that time. At a minimum, the Plan of Care is to be reviewed on a daily basis and is the responsibility of the Registered Nurse assigned to the care of the patient.
· Patient assessment and specialty plan (i.e., nutritional, respiratory, functional, discharge plans, etc.) are provided by the clinical specialty needed to provide comprehensive care as identified in the assessment performed by the medical and nursing staff.
· Patient educational needs assessment is performed during the Admission Assessment by the Registered Nurse. Where possible, education associated with the patient ' s diagnosis and care needs will be provided by the care provider in the language and manner the patient and/or family requests.
· Medication administration will be documented by the individual providing the
Medication in the E-MAR or the paper MAR during downtime (E-MAR)

Discharge Documentation
Discharge planning begins upon admission and is completed at time of discharge. The nursing assessment and the interdisciplinary plan of care are utilized in discharge planning. These tools are utilized to determine which patient problems have been resolved and to discuss means to achieve the desired outcome of any unresolved problems. Outcomes must be documented as achieved, partially achieved, or not achieved prior to discharge. A printed and/or electronic copy of the discharge summary will be given to the patient upon discharge. All post-hospital instructions, including restrictions, medications, pain management, diet considerations, referrals, physician follow-up, etc., should be completed in terms and/or language that the patient will understand. The hospital-approved electronic patient education system will be utilized for any educational materials and a signed copy is to be included in the patient ' s medical record. Understanding by the patient and/or family should be verified and documented in the EMR in the discharge documentation.