HospitalInspections.org

Based on document reviews and interviews, it was determined the Emergency Department staff did not follow their medical care policies and procedures for one (1) of ten (10) sampled ED patients (ED Patient #5).

Findings:

The hospital's "Patient Screening, Assessment, Planning, and Provision of Care" policy, last updated in January 2022, states, in part:

- "Patients will receive care based on a documented assessment of the needs and plan of care."
(F)- Provisions for Care, #3
- "All direct patient care givers are expected to document to a plan of care which includes assessment, information, interventions, and outcomes."

(D) - Plan of Care (POC) /Treatment Plan
- "All staff involved with the provision of care is responsible for adherence to this policy."
(III) - Responsibility

ED Patient #5's medical record for his/her visit to the ED on 12/19/2022 was reviewed with Director #1 on 4/19/2023. Director #1 confirmed Physician #1 had ordered Clinical Institute Withdrawal Assessment for Alcohol scale ("CIWA") assessments to be performed every four (4) hours on ED Patient #5. Director #1 confirmed that the patient had a CIWA assessment performed at 4 PM on 12/20/2022 and that another CIWA assessment was not performed and documented until 3:30 AM on 12/21/2022.

During this interview at 10:55 AM on 4/19/2023, Director #1 confirmed that the patient "should have received CIWA scores at 8:00 PM and 12:00 AM."