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Based on interview and documentation review the physician failed to assess/document the percentage of total body surface area (TBSA; considered when considering treatment options such as inpatient verses outpatient and referral to burn centers) affected by burns and failed to ensure that the Patient was medicated for pain prior to discharge from the Emergency Department (ED).

Findings included:

The medical record documentation indicated that the Patient received thermal burns on the face, neck, and left arm while opening a vent on a steam pipe at work. Following the incident the Patient was placed in a cold shower, ice was applied to the face, and the Patient was transported by ambulance to the ED for treatment.

The medical record documentation indicated that the Patient was evaluated by the ED Physician. Documentation indicated the Patient had redness on the face, neck, left ear and dorsum of the left arm. There were a few intact blisters on the Patient's face and one intact blister on the left arm. Documentation did not indicate the percentage of TBSA burned.

The medical record documentation indicated that the Patient rated the pain as 10/10 (on a scale of 1 to 10; 10 represents the worst possible pain) and described the pain as sharp and burning.

The Hospital's Policy/Procedure titled Pain Management indicated that the level of pain was assessed for all patients who presented to the Hospital. Pharmacological and non-pharmacological interventions could be used to treat the pain. Pain was reassessed after each intervention to determine effectiveness of intervention(s).

The medical record documentation indicated that cool saline compresses were applied to the burns followed by application of bacitracin ointment, Telfa dressings (a nonstick dressing), and gauze. There was no evidence that pain medication was administered.

The medical record documentation indicated that the Patient was discharged to home with a prescription for Vicodin for pain management.

The ED Physician was interviewed on 5/5/10 at 1:20 P.M. The ED Physician said the Patient should have received a dose of pain medication prior to discharge.

Based on interview and documentation review the Emergency Department (ED) Nurse failed to administer a tetanus injection to the Patient prior to discharge from the ED.

Findings included:

Review of the Patient's medical record documentation indicated that a tetanus injection was ordered but not administered. Documentation indicated the Patient was notified to follow-up with Occupational Health.

The ED Nurse assigned to the Patient was interviewed on 5/5/10 at 9:35 A.M. The ED Nurse said the Patient had left with family members before the tetanus injection was administered. The ED Nurse reported not communicating with the Patient regarding the need for the injection. The ED Nurse reported calling the Patient at home and telling the Patient to notify Occupational Health that a tetanus injection was needed.

Based on documentation review the ED Physician failed to document the percentage of total body surface area affected by burns.

Findings included:

Please refer to A-0467.