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Based on review of documents, medical records and staff interview, it was determined the hospital failed to protect and promote each patient's rights. The hospital failed to ensure the patient's right to be free from restraint (see tag A0154); The hospital failed to ensure restraints were used after failure of less restrictive methods were attempted (see tag A0164); The hospital failed to ensure the type of restraint was least restrictive (see tag A0165); The hospital failed to ensure the use of restraint was in accordance to a written modification to the plan of care (see tag A0166); The hospital failed to ensure the use of restraints was in accordance with an order from a physician (see tag A0168); The hospital failed to ensure the patient was reassessed prior to a renewal order for restraints (see tag A0172); The hospital failed to ensure the use of restraints was discontinued at the earliest possible time (see tag A0174); The hospital failed to ensure the condition of the restrained patient was monitored (see tag A0175); The hospital failed to ensure a description of the patients behavior and interventions used were documented (see tag A0185); The hospital failed to ensure documentation of the condition of the patient warranting the use of restraints (see tag A0187); The hospital failed to document the rationale for continued use of restraints (see tag A0188).

Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure the patient was free from physical restraints imposed as discipline in one (1) of four (4) medical records reviewed for restraints (patient #5). This has the potential to negatively affect all hospitalized patients by interfering with their right to be free from restraints.

Findings include:
1. Hospital policy titled, "Restraining a Patient", last revised 2/10, states in part: "Restraint will not be used as a means of coercion, discipline, convenience or retaliation by staff."

2. Patient #5 was admitted to the hospital on 5/1/10. Nursing documentation on 5/4/10 at 2:30 am states: "Patient keeps on getting out of bed and walking around her room, she keeps on saying it is her house and that we are messing around with things. We finally got her back in bed and then she would get right back up. Then patient went in her bathroom and she wouldn't come back to bed, so called Hospitalist for a restraint order. Had patient put on vest and assisted her back to bed and restrained her along with ankle restraints because patient keeps on kicking her legs off the bed. Patient very upset. Nursing Assistant sat with her for a few minutes, but patient was still upset." At 4:10 am, nursing documents, "patient pulled IV catheter out, so put wrist restraints on her arms, because patient pulled out lines and was hitting at staff." The restraint flowsheet documents the patent had vest, ankle and wrist restraints on at 2:30 am and also documents all four (4) side rails are raised. The patient remained in the supine position for eight (8) hours.

Physician verbal orders dated 5/4/10 at 2:30 am are for torso and limb (upper and lower) restraints. On 5/5/10 at 9:30 am, a physician verbal order is written to reorder vest restraint. The restraint flowsheet documentation by nursing indicates patient was in a vest restraint at 8:55 am. and all four (4) side rails were raised. There is no documentation to indicate when the restraints were removed.

3. This medical record was reviewed with the Clinical Nurse Manager of 7 South in the morning of 5/4/10 and again on 5/5/10 and she agreed with these findings.

Based on review of documents, medical records and staff interview, the hospital failed to ensure the staff used less restrictive interventions prior to the application of restraints in four (4) of four (4) medical records reviewed for restraint use (patients #1A, 1B, 5 and 6). This has the potential to negatively affect hospitalized patients by interfering with their right to be free from restraint or seclusion.

Findings include:

1. Hospital policy titled, "Restraining a Patient", last revised 2/10, states in part: "restraint of any kind should be used only after assessment and less restrictive approaches are considered ineffective or not feasible."

2. Patient #1A was admitted to the hospital on 12/2/09 and discharged 12/9/09. The Emergency Department (ED) nurse's notes state: "Kerlix applied around IV site. Right wrist restrained to prevent patient from removing IV". There was no documentation indicating less restrictive methods had been attempted. On 12/4/09, nursing documents,, "patient sleeping, wrist restraints on. Mother at bedside." No evidence of alternative methods attempted. Again on 12/6/09 and 12/7/09, nursing documents, "wrist restraints on, mother at bedside." On 12/9/09, nursing documents "patent with restraints loosened to give movement-Pulled telemetry wires loose. Restraints tightened, Mother at bedside." Documentation does not include the use use of less restrictive measures.

3. Patient #1B was admitted to the hospital on 3/18/10 and discharged on 3/24/10. On 3/18/10, nursing notes indicate restraints per mother request. There is no documentation to indicate less restrictive measures were tried.

4. Patient #5 was admitted to the hospital on 5/1/10. Nursing documents restraint use on 5/4/10 and 5/5/10. Documentation does not include use of less restrictive measures.

5. Patient #6 was admitted to the hospital on 4/29/10. Nursing documents restraint use on 5/1/10, 5/2/10, 5/3/10, 5/4/10 and 5/5/10. Documentation does not include use of less restrictive measures.

6. These medical records were reviewed with the Clinical Nurse Managers on 6 South and 7 South in the morning of 5/4/10 and afternoon of 5/5/10 and they agreed with these findings.

Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure the use of restraints were the least restrictive intervention used in four (4) of four (4) medical records reviewed for restraint use (patients #1A, 1B, 5 and 6). This has the potential to negatively affect the patient's right to be free from restraint.

Findings include:

1. Hospital policy titled, "Restraining a Patient", last revised 2/2/10, states in part: "restraint of any kind should be used only after assessment and less restrictive approaches are considered ineffective or not feasible".

2. Patient #1A was admitted to the hospital on 12/2/09 and discharged 12/9/09. The Emergency Department (ED) nurse's notes state: "Kerlix applied around IV site. Right wrist restrained to prevent patient from removing IV". There was no documentation indicating less restrictive methods had been attempted. On 12/4/09, nursing documents, "patient sleeping, wrist restraints on. Mother at bedside." No evidence of less restrictive methods attempted. Again on 12/6/09 and 12/7/09, nursing documents, "wrist restraints on, mother at bedside." On 12/9/09, nursing documents "patent with restraints loosened to give movement-Pulled telemetry wires loose. Restraints tightened, Mother at bedside."

3. Patient #1B was admitted to the hospital on 3/18/10 and discharged on 3/24/10. On 3/18/10, nursing notes indicate restraints per mother request . Documentation does not include use of less restrictive measures.

4. Patient #5 was admitted to the hospital on 5/1/10. Nursing documents restraint use on 5/4/10 and 5/5/10. Documentation does not include use of less restrictive measures.

5. Patient #6 was admitted to the hospital on 4/29/10. Nursing documents restraint use on 5/1/10, 5/2/10, 5/3/10, 5/4/10 and 5/5/10. Documentation does not include use of less restrictive measures.

6. These medical records were reviewed with the Clinical Nurse Managers on 6 South and 7 South in the morning of 5/4/10 and afternoon of 5/5/10 and they agreed with these findings.

Based on review of medical records and staff interview it was determined the hospital failed to ensure a written modification was addressed on the patient's plan of care in four (4) of four (4) medical records reviewed for restraints (patients #1A, 1B, 5 and 6). This has the potential to negatively affect the care of the patient by nursing not doing a complete assessment of the change in patient care.

Findings include:

1. Patient #1A was admitted to the hospital on 12/2/09. Restraints were initiated on 12/4/09 and continued through 12/9/09. The Interdisciplinary Plan of Care was not updated to include the use of restraints.

2. Patient #1B was admitted to the hospital on 3/18/10. Restraints were initiated on 3/18/10 and continued through 3/24/10. The Interdisciplinary Plan of Care was not updated to include the use of restraints.

3. Patient #5 was admitted to the hospital on 5/1/10. Restraints were initiated on 5/4/10 through 5/6/10. The Interdisciplinary Plan of Care was not updated to include the use of restraints.

4. Patient #6 was admitted to the hospital on 4/29/10. Restraints were initiated on 5/1/10 through 5/6/10. The Interdisciplinary Plan of Care was not updated to include the use of restraints.

5. These records were reviewed with the Clinical Nurse Managers in the morning of 5/4/10 and the afternoon of 5/5/10. They agreed with these findings.

Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure an order was obtained from the physician for the use of restraints in four (4) of four (4) medical records reviewed for restraint orders (patients #1A, 1B, 5 and 6). This has the potential to negatively affect all hospitalized patients by staff applying restraints inappropriately.

Findings include:

1. Hospital policy titled, "Restraining a Patient", states in part: "A physician may order that his or her patient be restrained while hospitalized...."

2. Patient #1A was admitted to the hospital on 12/2/09. Soft wrist restraints were ordered on 12/4/09, 12/5/09, 12/6/09, 12/7/09, 12/8/09 and 12/9/09. Nursing documents the use of soft wrist restraints along with all four (4) side rails raised. There was no physician order for the side rails.

3. Patient #1B was admitted to the hospital on 3/18/10. Soft wrist restraints were ordered on 3/18/10, 3/19/10, 3/20/10, 3/21/10, 3/22/10 and 3/23/10. Nursing documents the use of wrist restraints along with all four (4) side rails raised. There was no physician order for the side rails.

4. Patient #5 was admitted to the hospital on 5/1/10. Vest restraint and soft wrist and ankle restraints were ordered on 5/4/10 and only a vest restraint was ordered 5/5/10. Nursing documents the use of ordered restraints along with all four (4) side rails raised. There was no physician order for the side rails.

5. Patient #6 was admitted to the hospital on 4/29/10. Vest restraints were ordered on 5/2/10, 5/3/10 and 5/4/10. Nursing documents the use of vest restraint along with all four (4) side rails raised. There was no physician order for the side rails.

6. These medical records were reviewed with the Clinical Nurse Managers in the morning and afternoon of 5/4/10 and they agreed with these findings.

Based on review of medical records and staff interview, it was determined the hospital failed to ensure the physician documented a re-evaluation of the patient supporting the continued use of restraints in four (4) of four (4) medical records reviewed for restraints (patients #1A, 1B, 5 and 6). This has the potential to cause harm to all patients being restrained for extended periods of time.


Findings include:

1. Patient #1A was admitted to the hospital on 12/2/09. Restraints were initiated on 12/4/09. Renewal orders were written on 12/5/09, 12/6/09, 12/7/09, 12/8/09 and 12/9/09. There was no documentation from the physician indicating an assessment had been performed supporting the continued use of restraints.

2. Patient #1B was admitted to the hospital on 3/18/10. Restraints were initiated on 3/18/10 per physician order. Renewal orders for restraints were written on 3/19/10, 3/20/10, 3/21/10, 3/22/10 and 3/23/10. There was no documentation from the physician indicating an assessment had been performed supporting the continued use of restraints.

3. Patient #5 was admitted to the hospital on 5/1/10. Restraints were initiated on 5/4/10 per physician order. Renewal orders for restraints were written on 5/5/10 without written documentation from the physician indicating an assessment had been performed supporting the continued use of restraints.

4. Patient #6 was admitted to the hospital on 4/29/10. Restraints were initiated on 5/1/10 per physician order. Renewal orders for restraints were written on 5/2/10, 5/3/10 and 5/4/10 without written documentation from the physician indicating an assessment had been performed supporting the continued use of restraints.

5. These medical records were reviewed with the Clinical Nurse Managers of 6 South and 7 South in the morning and afternoon of 5/4/10 and they agreed with these findings.

Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure the use of restraints was discontinued at the earliest possible time in four (4) of four (4) medical records reviewed for restraints (patients #1A, 1B, 5 and 6). This has the potential to negatively affect patients by leaving them restrained unnecessarily.

Findings include:

1. Hospital policy titled, "Restraining a Patient", last revised 2/10, states in part: "Patients may be released from restraint prior to expiration of the time limited order if appropriate."

2. Patient #1A was admitted to the hospital on 12/2/09. Orders for wrist restraints were written on 12/4/09, 12/5/09, 12/6/09, 12/7/09, 12/8/09 and 12/9/09. Documentation on the restraint flowsheet indicates the patient remained in restraints from 12/4/09 through discharge on 12/9/09 without an assessment to attempt discontinuation.

3. Patient #1B was admitted to the hospital on 3/18/10. Orders for wrist restraints were written on 3/18/10, 3/19/10, 3/20/10, 3/21/10, 3/22/10 and 3/23/10. Documentation on the restraint flowsheet indicates the patient remained in restraints from 3/18/10 through discharge on 3/23/10 without an assessment to attempt discontinuation.

4. Patient #5 was admitted to the hospital on 5/1/10. Orders for vest and limb restraints were written on 5/4/10. Documentation on the restraint flowsheet indicates the patient was left in the supine position for six (6) hours without an attempt to discontinue the restraints. Orders were given for a vest restraint on 5/5/10. The restraint flow sheet does not indicate when the patient was released or if an attempt was made to discontinue at the earliest possible time.

5. Patient #6 was admitted to the hospital on 4/29/10. Orders for a vest restraint were written on 5/1/10 and renewed on 5/2/10, 5/3/10 and 5/4/10. There is no documentation on the restraint flowsheet to indicate an attempt to discontinue the restraint.

6. These medical records were reviewed with the Clinical Nurse Manager of 6 South and 7 South in the morning and afternoon of 5/4/10 and they agreed with these findings.

Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure monitoring of the restrained patient was done in accordance with hospital policy in four (4) of four (4) medical records reviewed for restraints (patients #1A, 1B, 5 and 6). This has the potential to cause harm to patients in restraints.

Findings include:

1. Hospital policy titled, "Restraining the Patient", last revised 2/10, states in part: "While the patient is restrained, the RN (or other trained caregivers) documents at least every two (2) hours assessment, observation and interventions.....".

2. Patient #1A was admitted to the hospital on 12/2/09. Restraints were initiated on 12/4/09. Nursing failed to document two (2) hour assessments. On 12/4/09, nursing failed to document an assessment for four (4) hours; on 12/6/09, nursing failed to document an assessment for three (3) hours; on 12/9/09, nursing failed to document an assessment for four (4) hours.

3. Patient #1B was admitted to the hospital on 3/18/10. Restraints were initiated on 3/18/10. Nursing failed to document two (2) hour assessments. On 3/20/10, nursing failed to document an assessment for six (6) hours; on 3/23/10, nursing failed to document an assessment for four (4) hours.

4. Patient #5 was admitted to the hospital on 5/1/10. Restraints were initiated on 5/4/10. Nursing failed to document an assessment on 5/5/10 while the patient was in restraints.

5. Patient # 6 was admitted to the hospital on 4/29/10. Restraints were initiated on 5/1/10. On 5/2/10, nursing failed to document an assessment for three (3) hours; on 5/3/10, nursing failed to document an assessment for nine (9) hours.

6. These medical records were reviewed with the Clinical Nurse Managers in the morning and afternoon of 5/4/10 and they agreed with these findings.

Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure the documentation of a description of the patient's behavior and the intervention used in four (4) of four (4) medical records reviewed for restraints (patients #1A, 1B, 5 and 6). This has the potential to negatively impact patient care by the application of restraints unnecessarily.

Findings include:

1. Hospital policy titled, "Restraint of Patients", last revised 2/10, states in part: "When restraints are initiated, the circumstances requiring patient restraint is documented in the medical record to include time, justification, type of restraint, patient's reaction, teaching of patient/family".

2. Patient #1A was admitted to the hospital on 12/2/09. Initial orders for restraint were written on 12/4/09 and renewal orders were written daily through 12/9/09. There was no documentation describing the patient's behavior and other interventions used.

3. Patient #1B was admitted to the hospital on 3/18/10. Initial orders for restraint were written on 3/18/10 and renewal orders were written daily through 3/24/10. There was no documentation describing the patient's behavior and other interventions used.

4. Patient #5 was admitted to the hospital on 5/1/10. Initial orders for restraint were written on 5/4/10. Renewal orders were written on 5/5/10 without documentation describing the patient's behavior and other interventions used.

5. Patient #6 was admitted to the hospital on 4/29/10. Initial orders for restraint were written on 5/1/10. Renewal orders were written on 5/2/10, 5/3/10, and 5/4/10 without documentation describing the patient's behavior and other interventions used.

6. These medical records were reviewed with the Clinical Nurse Managers of 6 South and 7 South in the morning and afternoon of 5/4/10 and they agreed with these findings.

Based on review of medical records and staff interview, it was determined the hospital failed to ensure the documentation of the patient's condition or symptom warranting the use of restraints in four (4) of four (4) medical records reviewed for restraints (patients #1A, 1B, 5 and 6). This has the potential to negatively affect all patients by unnecessary use of restraints.

Findings include:

1. Patient #1A was admitted to the hospital on 12/2/09. Orders were written for restraints on 12/4/09 through 12/9/09. There was no documentation in the medical record describing the condition or symptom warranting the use of restraint.

2. Patient #1B was admitted to the hospital on 3/18/10. Orders for restraints were written daily 3/18/10 through 3/24/10 without documentation in the medical record describing the condition or symptom warranting the use of restraint.

3. Patient #5 was admitted to the hospital on 5/1/10. Orders were written for restraints on 5/4/10 and 5/5/10. There was no documentation in the medical record describing the condition or symptom warranting the use of restraints.

4. Patient #6 was admitted to the hospital on 4/29/10. Orders for restraints were written daily on 5/1/10 through 5/5/10 without documentation in the medical record describing the condition or symptom warranting the use of restraints.

5. These medical records were reviewed with he Clinical Nurse Managers of 6 South and 7 South in the morning and afternoon of 5/4/10 and they agreed with these findings.

Based on review of medical records and staff interview, it was determined the hospital failed to ensure the documentation of the patient's response to restraints and the rationale for the continuation of the restraints in four (4) of four (4) medical records reviewed (patients #1A, 1B, 5 and 6). This has the potential to negatively affect all patients by the inappropriate use of restraints.

Findings include:

1. Patient #1A was admitted to the hospital on 12/2/09. Orders for restraints were written daily on 12/4/09 through 12/9/09. There was no documentation in the medical record including the rationale for continued use of restraints.

2. Patient #1B was admitted to the hospital on 3/18/10. Orders for restraints were written daily on 3/18/10 through 3/24/10. There was no documentation in the medical record including the rationale for continued use of restraints.

3. Patient #5 was admitted to the hospital on 5/1/10. Orders for restraints were written on 5/4/10 and 5/5/10 without documentation in the medical record including the rationale for continued use of restraints.

4. Patient #6 was admitted to the hospital on 4/29/10. Orders for restraints were written daily on 5/1/10 through 5/4/10 without documentation in the medical record including the rationale for continued use of restraints.

5. These medical records were reviewed with the Clinical Nurse Managers of 6 South and 7 South in the morning and afternoon of 5/4/10 and they agreed with these findings.

A. Based on review of medical records and staff interview, it was determined the hospital failed to ensure nursing followed physician orders in one (1) of ten (10) medical records reviewed for physician orders being followed (patient #1B). This has the potential to negatively affect all hospitalized patients by inappropriate and inadequate care rendered [WV00005632].

Findings include:

1. Patient #1B was admitted to the hospital on 3/18/10 for hip replacement surgery. On 3/20/10, the physician ordered a fleets enema to be given. Nursing failed to carry out the order, causing the physician to rewrite the order on 3/21/10.

2. This medical record was reviewed with the Clinical Nurse Manager of 6 South in the afternoon of 3/4/10 and she agreed with these findings.


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B. Based on document review, medical record review and staff interview, it was determined the hospital failed to ensure the Emergency Department (ED) Registered Nurses (RNs) followed hospital policy when documenting ongoing assessments of vital signs of patients in ten (10) out of ten (10) records reviewed (patients #1, 2, 3, 4, 5, 6, 7, 8, 9, 10). This has the potential to negatively impact all ED patient care by missing changes in patient condition [WV00005605].

Findings include:

1. Charleston Area Medical Center ED policy, Vital Signs, last revised 2008, states in part "...2. The frequency of reassessment is based on the patient's acuity, condition...minimally every four (4) hours..."

2. Charleston Area Medical Center policy, Triage in the Emergency Department, last revised 2008, states in part "... 3. Determine patient's Triage category. Category is based on patient's acuity and in accordance with the Standard for West Virginia designated Trauma Centers...Category II-Emergent: ...patient must be triaged rapidly to a treatment area with initiation of basic monitoring and treatment procedures...Category III-Urgent: ...must be reassessed at least every hour to determine any changes in triage level....Category IV-Non-Urgent: ...must be reassessed at least every two (2) hours to determine any change in triage level."


3. Review of the medical record for Patient #1 revealed the patient was triaged at the Memorial Division ED at 0440 as Urgent with vitals taken only at the time of triage and 0700. The patient was then transferred to the General Division ED and triaged at 0800 as Non-Urgent. The vitals documented on the triage assessment form at the General Division were identical to the discharge vitals documented from the Memorial Division. Vitals were then documented at discharge at 1635. There is no other documented evidence of vital signs being reassessed during this time period.

4. Review of the medical record for Patient #2 revealed the patient was triaged on 1/12/10 at 1940 as Urgent. There is documented evidence the patient's vitals were taken at triage and again on 1/13/10 only at 0100, 0330 and at discharge at 1029.

5. Review of the medical record for Patient #3 revealed the patient was triaged at 0028 as Urgent. There is no documented evidence the patient's vital signs were taken until discharge at 0910.

6. Review of the medical record for Patient #4 revealed the patient was triaged at 1320 as Urgent. There is documented evidence in the medical record the patient's vital signs were only assessed at triage and again at 2100.

7. Review of the medical record for Patient #5 revealed the patient presented to the ED at 1549, was triaged at 1630 as Urgent and sent back to the waiting room, then taken to an exam room at 2040. There is documented evidence of the patient's vitals being assessed at triage and again at 1837 and not again until discharge at 2230.

8. Review of the medical record for Patient #6 revealed the patient was triaged on 1/13/10 at 1915 as Urgent. There is no documented evidence the vital signs were assessed until 1/14/10 at 0000 and reassessed at 0300, 0440, 0600 and 0945.

9. Review of the medical record for Patient #7 revealed the patient was triaged on 1/13/10 at 2257 as Urgent. There is documented evidence the patient's vitals were assessed at triage but not again until discharge on 1/14/10 at 0300.

10. Review of the medical record for Patient #8 revealed the patient was triaged at 1054 as Urgent. There is documented evidence the patient's vital signs were assessed at triage but not again until discharge at 1800.

11. Review of the medical record for Patient #9 revealed the patient was triaged at 0505 as Urgent. There is documented evidence the patient's vital signs were assessed at triage but not again until discharge at 0910.

12. Review of the medical record for Patient #10 revealed the patient was triaged at 0130 as Emergent. There is documented evidence the patient's vital signs were taken at triage and reassessed only at 0300, 0500, 0630, 0955 and 1340.

13. During an interview in the morning of 5/6/10, the ED Director reviewed the medical records and agreed with the above findings.

Based on review of documents, medical records and staff interview, it was determined the hospital failed to ensure nursing kept current a care plan for four (4) of four (4) medical records reviewed for restraints (patients #1A, 1B, 5 and 6). This has the potential to negatively affect patient care by nursing failing to assess the patient's needs and interventions to assist with patient's needs.

Findings include:

1. Hospital policy titled, "Restraining a Patient", last revised 2/2010, does not direct staff to update the Plan of Care per Federal Regulations.

2. Patient #1A was admitted to the hospital on 12/2/09. Restraints were applied on 12/4/09 through 12/9/09 and the Interdisciplinary Plan of Care was not updated to include restraints.

3. Patient #1B was admitted to the hospital on 3/18/10. Restraints were applied on 3/18/10 through 3/24/10 and the Interdisciplinary Plan of Care was not updated to include the use of restraints.

4. Patient #5 was admitted to the hospital on 5/1/10. Restraints were applied on 5/4/10 and 5/5/10 and the Interdisciplinary Plan of Care was not updated to include the use of restraints.

5. Patient #6 was admitted to the hospital on 4/29/10. Restraints were applied on 5/1/10 through 5/5/10 and the Interdisciplinary Plan of Care was not updated to include the use of restraints.

6. These medical records were reviewed with the Clinical Nurse Managers of 6 South and 7 South and they agreed with these findings.

Based on medical record review and staff interview, the hospital failed to ensure the Emergency Department (ED) medical staff dates and times the handwritten medical screening exam (MSE) in seven (7) of ten (10) medical records (patients #1, 2, 3, 4, 5, 8, 10) reviewed. This has the potential to negatively impact all ED patient care by not establishing a timeline of events.

Findings include:

1. Review of the medical record for Patient #1 revealed the patient was triaged at the Memorial Division ED at 0440 as Urgent and taken to the exam room at 0445. The patient was then transferred to the General Division ED, triaged and taken to the exam room at 0800. There is no documented evidence on the Physician's ED Record of the date and time of the MSE at either ED.

2. Review of the medical record for Patient #2 revealed the patient was triaged at 1940 as Urgent with no documented evidence on the Physician's ED Record of the date and time of the MSE.

3. Review of the medical record for Patient #3 revealed the patient was triaged at 0028 as Urgent with no documented evidence on the Physician's ED Record of the date and time of the MSE.

4. Review of the medical record for Patient #4 revealed the patient was triaged at 1320 as Urgent with no documented evidence on the Physician's ED Record of the date and time of the MSE.

5. Review of the medical record for Patient #5 revealed the patient was triaged at 1630 as Urgent with no documented evidence on the Physician's ED Record of the date and time of the MSE.

6. Review of the medical record for Patient #8 revealed the patient was triaged at 1054 as Urgent with no documented evidence on the Physician's ED Record of the date and time of the MSE.

7. Review of the medical record for Patient #10 revealed the patient was triaged at 0130 as Emergent with no documented evidence on the Physician's ED Record of the date and time of the MSE.

8. During an interview in the morning of 5/6/10, the ED Director reviewed the medical records and agreed with the above findings.