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Based on review of the medical record and interviews, it was determined that the Hospital failed to ensure medical record entries were complete and documented the course of care related to tetanus immunization in patients with an unknown tetanus immunization status in one (Patient #1) of ten medical records reviewed.

Findings included:

1) Review of nursing triage documentation dated 7/26/11 at 5:52 P.M. indicated that Patient #1 had an injury to the face, nose and left knee related to a fall by tripping over an object and falling to the ground. Patient #1's tetanus immunization status was unknown.

Review of the Emergency Department (ED) Attending Physician's documentation dated 7/26/11 indicated that Patient #1 had facial abrasions and an abrasion on the right knee. Documentation did not indicate that a determination had been made related to need for administration of tetanus immunization.

The ED Attending Physician was interviewed in person on 12/21/11 at 3:15 PM. The ED Attending Physician said there was nothing listed in Patient #1's past medical record related to tetanus immunization status and Patient #1's primary care physician was not on staff at the Hospital to check Patient #1's tetanus status. The ED Attending Physician said that when a patient was admitted, the attending physician would follow-up on determining the status of immunity.

Review of the ED Attending Physician's documentation dated 7/26/11 indicated that Patient #1 was transferred from the Hospital's Peabody Campus to the Burlington Campus for trauma evaluation.

Review of the Nursing Triage documentation dated 7/27/11, 12:41 A.M. indicated that Patient #1 arrived at the Hospital's Burlington Campus ED and it was noted that Patient #1's tetanus immunization status was unknown.

Review of trauma evaluation documentation dated 7/27/11 indicated that Patient #1's tetanus immunization status was not established or addressed. Patient #1 was admitted to an in-patient nursing unit.

Review of physician progress notes dated 7/27/11-7/28/11 indicated that Patient #1's tetanus immunization status was also not established or addressed. Patient was discharged home on 7/28/11.

The Surgeon was interviewed in person on 12/29/11 at 3:15 P.M. The Surgeon said that typically the ED determines if a patient requires tetanus immunization.

The Trauma Resident was interviewed by telephone on 12/29/11 at 2:37 P.M. The Trauma Resident said if a patient's tetanus immunization status was unknown and there was a clinical indication for an injection, an order would be written to administer a tetanus immunization and the ED nurse would administer it.

The Surgical Resident was interviewed by telephone on 12/29/11 at 9:30 A.M. The Surgical Resident said tetanus immunization was part of the trauma protocol's initial assessment and order set. Administration of a tetanus immunization would depend on the type of injury, but in general, it would be given as a precautionary measure.