HospitalInspections.org

Based on observations, document reviews and staff interviews, it was determined that the facility did not maintain a central log for all patients that present for emergency care.

Findings include:

1. During observations conducted on September 18, 2012 at 2:15 p.m., it was noted that some Obstetric patients were triaged in the triage area on Labor and Delivery (L & D) Unit and that they were treated by the physicians on that unit.

During staff interviews conducted on September 18, at 2:20 p.m., Staff #5 stated that some Obstetric patients are sent directly from the Emergency Department (ED) to the L & D Unit where they are triaged, evaluated by a physician, admitted to the unit or discharged from the unit. Staff #5 stated that the names of patients for these visits are documented in the Obstetric Log (OB) Log.

Copies of the OB Log and the ED Log were reviewed to determine whether all the patients seen on the OB unit were documented in the ED central log. However, a review of the logs revealed that patients, who were seen on the OB unit, were not logged into the ED Central Log. For example, The ED Log for 8/13/11-8/21/11 and for 7/1/12-8/7/12 did not list any OB patient that visited the facility during the aforementioned time frames.

Therefore, the Hospital is not in compliance with this requirement: to maintain a central log for all patients that present for emergency care.

Based a review of patients' medical records, a of review of policies and procedures, a review of Emergency Room Logs and Obstetric Logs, including staff interviews, there was no evidence that all patients who presented for emergency care were stabilized prior to discharge. This was evident in 1 of 32 medical records reviewed. Medical Records # 1.


Findings include:


There was no documentation in MR#1 that this patient was stabilized prior to discharge from the facility.

This thirty year old 20 week primiagravida patient presented to the triage area of the Labor and Delivery Unit (L & D) on 11/19/11 at 6:04 a.m., with complaints of fever, chills and abdominal pain which awoke the patient at 2:00 a.m. that morning.

The patient had two Laminaria sticks inserted the previous day to facilitate a Dilation and Evacuation on 11/19/11 because the fetus had trisomy 18. Documentation in the medical record revealed that the patient's presenting symptom were: a pain score rated at 10/10 on a scale of (0 no pain -10 worse pain), the temperature was 36.4 C (97.52 F), there was tachycardic with a pulse rate of 129 beats per minute and the blood pressure was slightly elevated B/P (134/71).

According to a physician's documentation in the medical record, the patient appeared uncomfortable. This assessment was confirmed during staff interviews conducted on September 20, 2012 and September 24, 2012 with Staff #8 and Staff #9 respectively.

According to documentation in the medical record, the Laminaria sticks were removed and a baseline panel (bloodwork) was drawn. Vital signs that were repeated at 7:42 a.m., revealed that the patient's temperature had increased to 37.9 (100.2 F), the pulse remained rapid at 118/minute and the blood pressure had increased to 151/76. The patient was discharged at 7:48 that morning.

After discharge from the facility, the baseline panel was completed on 11/19/11 at 7:52 a.m., it indicated that the patient had an elevated white blood cell count of 36.9, an elevated neutrophil count of 77 and bands were 15.

There was no evidence that this patient's pain status was re-evaluated prior to discharge as required by the Hospital's policy and procedure.

The facility's policy and procedure titled "Pain Assessment and Management (last reviewed on 1/11 stated "If the patient reports pain, the following characteristics will be assessed: history, pain score, (intensity), location, pain goal, duration, patient's perception of pain origin, type (quality), patterns, relieving and aggravating factors and how pain affects activity, appetite, concentration and sleep and social relationships." Of these characteristics, only the pain score of 10/10 at the time of arrival was documented.

There was no evidence that this patient was recalled or followed up by the hospital after the facility received the abnormal lab results, including the (elevated) white blood cell count. Repeated requests on 9/20/12 for a policy and procedure on patient recall by the Emergency Room was not provided. Request for interviews with nursing staff were declined.

Given the patient's abnormal vital signs, pending lab work and undocumented pain score, it was unclear how the staff determined that this patient was stable prior to discharge.