HospitalInspections.org

Based on the results of an allegation survey, the governing body failed to comply with the requirements of 482.55, Emergency Services. The results of the survey determined that the facility was not in compliance with the conditions of participation for emergency services.

Findings:

Please see findings under A 1100 and A1101.

Based on document review, interview, and an independent physician review, the facility failed to comply with the requirements for the emergency department condition of participation. Specifically, the facility failed to provide care in accordance with acceptable standards of practice for both medical staff and nursing services, as well as a systemic failure related to the reporting and follow-up of abnormal laboratory results.

Findings:

The patient presented to the ED on 3/29/12 at 18:58. The patient's history and physical examination were suggestive of viral gastritis, fever, vomiting and dehydration. The physician reviewer identified that the standard of care was not met for the following reasons:

1)Nursing and physician staff failed to document a final reassessment of the patient's condition before discharge.

? a) The last vital signs were documented at 21:26. At that time, the temperature was 102F and the patient's heart rate was elevated, 131 beats per minute. ED staff failed to obtain a repeat temperature and heart rate prior to the patient's discharge at 22:32.

? b) Even though the patient was treated with Tylenol and two liters of intravenous fluid, ED staff failed to document an assessment of any changes in the patient's general appearance and the effectivieness of those interventions/treatments. ED staff failed to document the patient's intake and output; the ability to tolerate fluids by mouth even though the patient presented with complaints of vomiting, and obtain a second set of electrolytes. Electrolytes were reported as slightly low at 20:48, however there is no indication that a second set of electrolytes was obtained.

? c) Physician and nursing staff also failed to address the complaint of right leg pain even though the patient reported a pain level of 6/10 at the time of triage.

2) ED staff failed to assure that all pending test results were reviewed prior to the patient's discharge.

? a) The physician reviewer noted that the patient had an abnormal blood count (high bands of 53% for differential results). Although the complete blood count with differential was ordered as "stat" at 19:58, the differential results were not reported until 23:02, approximately 30 minutes after the patient was discharged from the emergency department. There is no documentation that the treating physician was aware of this abnormal result. It was confirmed on interview with the physician that he/she did not review the band results. The high band results should have raised the physician's concern for bacterial infection and the need for blood cultures and antibiotic coverage. On interview with the laboratory director, it was reported that a manual differential was warranted because of the initial automated band results being flagged, however, there was not a process in place to report the results of the abnormally high band count to the emergency department. The bands were reported as 53%, per the facility's laboratory report the normal range is 5-15%.

The facility failed to have a system in place to notify discharged patients concerning abnormal/critical laboratory results when the laboratory results were pending or not reviewed prior to discharge. There was no documentation that the facility attempted to notifiy the patient's family of the abnormal laboratory results that were pending at the time of discharge. It was confirmed on interview with Staff #4, on 8/9/12 that the facility only notified discharged patients of abnormal laboratory results for blood and urine cultures, and positive serology/titers.

Based on staff interview, medical record and, document review, it was determined that the facility failed to provide appropriate emergency care in 2 of 21 medical records reviewed. Specifically, physical assessments were incomplete. This was found in medical records (MR) #2 and #3.

Findings include:

1. The history and physical assessments were incomplete. MR #2 is a 4 month infant that presented to the ED on March 29, 2012 after she had fallen 1 ? feet onto a hardwood floor. The circumstances of the fall were not documented. The assessment included reviews of the patient's ear, nose and throat, eyes and respiratory status. There was no documented evidence that the skin and neurological status were assessed.

2. MR #3 is a 1 year old child who presented to the ED on March 29, 2012 after he had fallen from a high chair and sustained an injury to the nose. The patient also had a 1 cm hematoma to the forehead. The medical record lacked any further documentation regarding the circumstances of the fall and the assessment was incomplete.