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Based on record review and interview the facility failed to ensure medical records were accurate for 1 patient (#1) out of 10 emergency room (ER) patients whose medical records were reviewed. The failed practice placed the patient at risk of receiving incorrect discharge instructions for foot care. Findings:


Patient #1


Record review on 2/3-4/14 of the triage documentation revealed Patient #1 had received services through the emergency room (ER) on 1/12/14 at 11:45 am. The patient ' s discharge summary noted the Patient's feet had possible minor frostbite with fluid-filled blisters. Final impression from the emergency department (ED) attending physician was "Bilateral foot blisters, possible cold injury to bilateral feet."


Further review of the medical record revealed Patient #1 was given discharge instructions for foot care that included the following: "Apply ice for 20 minutes allowed tissue to re-warm for an hour, repeat at least 5 times a day for pain and swelling."


On 2/4/14 at 8:50 am the surveyor questioned the ED Director concerning the appropriateness of the discharge instructions for the Patient's foot care. The Director disclosed the ED staff recognized the instructions were not correctly written, and therefore, prior to discharging the Patient had crossed out the incorrect portion of the order and had verbally told the Patient the correct way in which to take care of her injured feet. When the surveyor asked if the EPIC (hospital's electronic computer system) computer discharge instructions should have reflected the changed foot care orders, the ED Director confirmed the discharge instructions should have been changed in the EPIC computer system.


Review of the facilities policies and procedures provided to the surveyors by the Accreditation Program Manager revealed there was not policy that required staff to ensure corrections were made to the EPIC discharge orders when known mistakes were made initially.

Based on record review, policy review, and interview the facility failed to ensure needed services were provided for 1 patient (#1) out of 10 emergency room (ER) patients for which care and services were reviewed. The outcome of the failed practice resulted in the patient being discharged without adequate transportation assistance, which consequently resulted in the patient walking home in sub-zero weather only to return to the ER a few hours later with cold injury to bilaterally feet. Findings:

Review of Patient 1's medical history revealed he/she had a history of the following diagnoses: diabetes; Aspergers; schizophrenia; and bipolar disorders. Review of Patient 1's social history revealed he/she lived in an assisted living home; had a temporary guardian; and attended a local school.

First ER visit on 1/11/14, arrived at 9:47 pm.

Medical review on 2/3-4/14 revealed Patient 1 came into the facility's ER on 1/11/14 at 9:47 pm with a chief complaint of accidental overdose of insulin. The Patient said he/she was supposed to have taken 25 units of insulin and mistakenly took 125 units of insulin. The patient complained of being dizzy and also complained of having a sore right hand after bumping his/her hand against a window a couple of days earlier. The hospital did a blood glucose test and found his/her blood sugar to be 63. The Patient told the hospital staff that lately his/her blood sugars had been in the 400s.

Additional medical record review revealed the hospital completed labs that included a basic metabolic panel and a urinalysis. The outcome of these labs revealed the Patient was low in potassium. The urinalysis was negative for infection. The hospital also did an x-ray of the Patient's right hand which revealed no bone fractures.

The 1/11/14 triage nurses' documentation revealed, "Pt took 125 units of Novalog insulin by mistake, States [he/she] was tired and wasn't thinking and was to take 25 units but took 125 instead. Takes Lantus 65 units every morning; [and] takes 10 units and sliding scale with each meal. Pt has a long history of Schizophrenia and Bi-Polar. Pt lives in House of Gold, Assisted Living Facility, has been there for 2 days. States "I don't want to be here, I just want to go home".

The 1/11/14 emergency room course documentation from the ER physician revealed, "18 y.o. [gender identification omitted] with history of diabetes and as per [his/her] presents after accidental overdose of insulin, NovoLog. [He/She] denies any other congestants is not on any oral hypoglycemic agents. [He/She] had normal renal function. Patient well appearing on serial examination; [He/She] was walking around in the hall without difficulty and toleration food. 12:32 (am) Patient discussed with the pharmacist peak onset of Novolog is 1-3 hours and durations is 3-5 hours. She anticipates that drug should be out of the system by 12 pm if the injection was about 7 pm. [He/She] has been observed in the emergency department (ED) for 5 ? hours following his/her ingestion and [his/her] final glucose is 130. I feel that he/she is medically stable for discharge and patient comfortable with plan of care."

"I discussed the results of the hand xray with the patient who agreed to follow up with [his/her] primary care physician as needed. Patient was discharged in stable condition."

Review of the hospital discharge instruction on 1/12/14 at 12:44 am revealed, "Please follow up with your primary care physician. Take your insulin with care. Return for worsening symptoms or new concerns."

Review of the record documentation concerning the Patient's "Departure Condition" on 1/12/14 at 12:47 am revealed, "Departure Mode: "By self."

Second ED visit on 1/12/14, arrived at 9:34 am

Review of the nurse triage notes on 1/12/14 at 9:33 am revealed, "Patient was seen in the ER here yesterday, [he/she] was discharged and actually walked home with open toed shoes, blister to feet, hx of diabetes and Aspergers. [He/She] is complaining of painful feet today."

Review of emergency department nurse's noted, dated 1/12/14 at 10:20 am, revealed "Pt reports left the ED early this morning between 0100 and 0200, walking home in open toed shoes. Pt c/o bilateral foot pain, swelling and numbness in all her toes, noted closed blister to right inferior anterior foot and instructed pt not to try and open it to prevent risk of infection, pt verbalized understanding. Noted mild swelling to bilateral feet, but skin is warm, pink and dry, cap refill less than 2 seconds to all toes. Pt reports [he/she] is able to ambulate, but it is painful. Pt also demonstrated full ROM of both feet without difficulty."

Review of the ED department physician's notes, dated 1/12/14 at 10:42 am, revealed "[patient's name omitted] is an 18 y.o. [gender omitted], with a history of diabetes and Aspergers and schizophrenia, who presents to the ED via EMS for a blisters on the bottom of her right foot. The patient was seen earlier this morning by [name omitted] after arriving by EMS because [he/she] accidentally overdosed on [his/her] insulin. The patient reports that [he/she] did not have a ride home after being discharged at approximately 01:00 so [he/she] walked home about mile and a half in open toed slippers to her assisted living home. [He/She] notes that no one was able to pick her up at that time. Upon arriving home [he/she] began to experience pain in [his/her] bilateral feet. [He/She] reports that [he/she] also had redness and swelling of [his/her] feet and that [he/she] feels as if [his/her] feet may be frost bitten. [Gender omitted] pain is localized to the location of [gender omitted] blisters and upon arrival to the ED [gender omitted] at a ten out of ten when standing or sitting. [Gender omitted] has took 400 mg of Ibuprofen with slight relief of [his/her] at 09:00, approximately two hours prior to arrival. The patient reports that [he/she] ate breakfast this morning and had a blood glucose level of 181."

Review of the physician's evaluation summary for the Patient revealed, "It's possible that [he/she] has some minor frostbite or frostnip. Recommend that [he/she] not allow [his/her] feet to refreeze. Right now there is no desquamation. [His/Her] feet are warm well-perfused without significant edema though [he/she] does have some fluid filled blisters. [He/She] should follow-up with [his/her] Dr. and return for signs of infection [he/she] was given a cab voucher to get back to [his/her] assisted-living."

"Discharged in good condition with a plan as outlined below. Upon [his/her] discharge, the patient is ambulating to the lobby on [his/her] heels."

Review of a nurse telephone follow-up call, dated 1/13/14 at 12:10 pm, revealed the Patient was asked 6 questions concerning [his/her] recent visits to the ED. Question 1 asked, "How are you doing since you were discharged yesterday from the Emergency Room? The Patient answered, "Worse". Question 6 asked, "Do you have any other concerns I can address at this time?" The Patient answered, "Yes, says [he/she] was not given a cab voucher or a bus pass and therefore had to walk home in open toe slippers and now [his/her] feet hurt for [him/her] to walk." The nurse documented "Advised to contact [his/her] PCP (primary care physician), [he/she] can also return to the ED at any time for worsening concerns. Says the ER Doc told [him/her] to go home on bed rest. This is not reflected in [his/her] records. Note also states [he/she] was given a cab voucher. Transferred to the operator to be transferred to the hospital social worker."

During a meeting on 2/4/14 at 8:47 am with the Accreditation Program Manager; the Director of the Emergency Department; the Emergency Department Clinical Nurse Supervisor; and the Risk Management Specialist the following information was disclosed. The Accreditation Program Manager said the Patient ' s initial visit to the ED should have been referred to social services to come and assist with the service needs and discharge. That when a patient comes in with a known history of mental illness and who arrives in an ambulance with no family or support person that the nursing staff should have immediately contacted the on-call social worker to evaluate the patient's needs. When the surveyor asked why the patient was not given a taxi voucher before leaving the hospital, the Manager said he did not know why the voucher was not given, that it was embarrassing to think the ED staff did not evaluate the Patient's transportation needs.

The surveyor asked the Director of the ED what the protocol was when a patient had medical needs beyond the normal duties of the nursing and doctor activities provided in the ED. The Director said the patient would be provided the services through the other departments of the hospital. When the surveyor asked why the Patient did not receive the social worker's consult, the Director did not have an answer. He did confirm that the Patient should have had the social worker contacting the ALF to see if transportation could be provided by their staff and if not the Patient should have received a taxi voucher. He also said the taxi vouchers were always available to patients who needed them.

The surveyor asked the Risk Management Specialist what the hospital's process was for identifying adverse events. The Risk Management Specialist said there were multiple ways in which his department received information. He said that the hospital had a policy that any patient who had multiple ED visits within a 72 hour period were supposed to be reported to the Risk Management Department. He said that someone from Risk Management made rounds through the ED everyday to check with the ED supervisor to see if there were any issues that needed to be looked into. He also said that the nurse 24-hour patient call-back staff were to report any potential adverse event reports that they received from patients. He confirmed the Patient's issues should have been reported to the supervisor. The Director of the ED said he spoke with doctor that met with the Patient on 1/11/14. The doctor did remember the Patient, and the first and second visit and regretted the adverse outcome.

Further interview with the Accreditation Program Manager and the other hospital staff at the 2/4/14 meeting confirmed the Patient's adverse event would have never happened if the hospital's normal protocol had been followed by the ED staff to contact social services to evaluate the patient's needs. In addition, the staff also agreed that even after the event took place the hospital's Risk Management should have been notified of the Patient's poor outcome so that an action plan could have been put into place.

Review of the hospital's policy and procedure, " Sentinel Events Reporting/Management", dated 1/14/12, revealed ... "V. Procedure - When a staff member identifies a potential sentinel event, the staff member shall take the following steps: A. Immediately report the event to the shift coordinator/manager who will then notify the appropriate Supervisor/Administrator for their specific area, Director - Risk Management, and/or Administrator on Call (AOC) as appropriate. The AOC and Director - Risk Management will notify Public Affairs and the appropriate leadership as needed or appropriate. B. Submit the event to Risk Management on the PHSA UOR Reporting system (UOR). C. Risk Management or designee will coordinate an initial investigation of the event with the Administrator or designee responsible for the area within 72 hours or less."