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Based on interview and record review, the facility failed to ensure that a patient presenting to the Emergency Department (ED) with an injury received stabilizing treatment before discharge in 1 of 1 patient (Patient #2).

Refer to 2407

Based on interview and record review, the facility failed to ensure that a patient presenting to the Emergency Department (ED) with an injury received stabilizing treatment before discharge in 1 of 1 patient (Patient #2).

This deficient practice had the likelihood to cause harm to all patients presenting to the ED with injuries.

Patient #2 was a 14-month-old child who had been bitten on the face by a dog, patient presented to the ED on 07/06/24, there was no documentation of wound care prior to discharge. Patient #2 was taken by the mother to facility #2 where the patient was assessed, wound care was provided, antibiotics were administered, and the patient was admitted for observation.

Findings include:

A review of the Electronic Health Record (EHR) for Patient #2 revealed the patient presented to the ED on 07/06/2024 at 2:32 PM with a complaint of a dog bite to the right cheek. Staff #11(Registered Nurse) documented that the wound was "red and swollen." In addition, Staff # 11 documented that the bite "occurred around 1:00 PM and no care was given before coming to the ED." Further review of the EHR, revealed there was no documentation found that the wound was cleaned by Staff # 11.

A review of the Electronic Health Record (EHR) revealed Patient #2 was evaluated by the Emergency Room Physician (Staff #16) on 07/06/2024 at 4:23 PM. Staff #16 documented that Patient # 2 had "2 minor abrasions/lacerations to the right cheek. These are both about 5 millimeters in length. Neither of them is gaping and neither requires any kind of cosmetic closure. They did not go through into the oral mucosa at all, and dentition is intact."

A review of the progress note for Physician #16 revealed there were no orders written for wound care, antibiotics, and/or antibiotic prescriptions. Patient #2 was discharged home with instructions to clean the wound.


A review of the facility's "ED Standards of Care Manual" policy dated 07/16/2024 revealed:


"PURPOSE:

* To provide evidence based medical care in the Emergency Department (ED)
* To provide guidelines for Emergency Department (ED) staff to follow to ensure high quality, safe patient care."


A review of the facility's "Emergency Medical Treatment and Active Labor Act (EMTALA)" policy dated 07/14/2022 revealed:

"INTRODUCTION
The purpose of this policy is to define the relevant terms and provide an overview of the Emergency Medical Treatment and Labor Act (EMTALA), the regulations and rules promulgated thereunder, and the State Operations Manual interpretive guidelines. This Emergency Medical Treatment and Patient Transfer policy is based on federal law relating to the obligations of hospitals to provide screening and emergency medical treatment and the appropriate transfer of individuals between hospitals. The treatment and transfer of an individual shall not be predicated upon arbitrary, capricious, or discrimination based upon race, color, religion, national origin, age, sex, sexual orientation or identification, diagnosis, physical condition, economic status, payor source, ability to pay, or other protected category. (Individual Hospitals should determine whether their state laws and regulations have any additional or different requirements than those set forth herein and ensure the Hospital's emergency medical treatment and patient transfer policy and procedures are in compliance with all applicable laws. Any apparent conflict between the state and federal laws should be discussed with the Legal Department.)

Stable for Discharge: A patient is stable for discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions; or the patient requires no further treatment and the treating physician has provided a written documentation of his/her findings."

The surveyor requested a wound care policy from the facility. No policy was provided.

An interview was conducted with Staff #13 (Director of ED- offsite) on 08/20/2024 at 10:30 AM. Staff #13 was asked about wound care for a patient with a dog bite. Staff #13 reported, "I'm sure it was cleaned." The chart was reviewed with Staff #13 and the Surveyor. Staff #13 stated, "I do not see any documentation that wound care was done." Staff #13 was asked if the facility or Emergency room staff receive any training related to wound care. Staff #13 stated, "There is not any specific wound care training that we do with the staff."

An interview was conducted with Staff #10 (Risk Manager) on 08/20/2024 at 10:45 AM. Staff #10 stated, "I am sure our nurses did wound care and maybe just forgot to document it. We should have at least done some wound care."

A review of the medical record with the Risk Manager and the Quality manager revealed there was no wound care documentation for Patient #2.

A review of the EHR from facility #2 revealed that Patient # 2 reported to the ED on 07/07/2024 at 4:59 PM with a complaint of worsening signs and symptoms of a dog bite to the face. The triage nurse documented "right side of face, now draining, hot to touch."

Further review of the EHR for facility #2 revealed Patient #2 was admitted to the facility for observation for facial Cellulitis, Acute Thrombocytosis, Acute Leukocytosis, and Acute Dehydration. Patient #2 received lab work, wound cultures, intravenous fluids, intravenous antibiotics, pain medication, and wound care during the admission.

A review of the Centers for Disease Control and Prevention reveals the following recommendations for dog bites;

"1. Make sure your pets are up-to-date on their rabies vaccines.
2. Keep wildlife away for both human and animal safety.
3. Wash bites or scratches immediately with soap and water.
4. Seek medical care shortly after potential exposures.
5. Rabies Postexposure Prophylaxis (PEP) includes wound washing, human rabies immune globulin (HRIG), and a four-dose series of vaccines."