HospitalInspections.org

Based on interview and medical record review, the facility failed to fully document the care provided to 2 of 13 ED patients.
Findings:
1. On 8/16/16, DOH staff reviewed the medical record of the Patient #1 who was seen in the ED on 3/19/16 at 6:30 PM. It did not include any reference to radiologic testing.

On 8/17/16, during a 10:00 AM interview, the ED physician stated that Patient #1 was to have a panorex, a two dimensional, x-ray, performed as an outpatient. The ED physican acknowledged that the intention to perform this radiologic test was not documented.

On 8/22/16, at 3:00 PM, the consulting dentist was interviewed. He stated his intention to perform a panorex film of the patient's jaw and teeth on 3/21/16. This was to be done as an outpatient. He stated that he discussed the x-ray with the patient. He acknowledged that neither the discussion, nor this portion of the plan of care, were documented.

2. On 8/17/16, DOH staff reviewed the medical record of Patient #2, a 53 year old female who entered the ED in an intoxicated state. The patient arrived in the ED on 6/17/16 at 7:09 PM. She had a blood alcohol level of 383. The patient's family stated that she had taken a fall and that she was unconcscious for 10 minutes. She was evaluated in the ED for altered mental status and a possible head injury. At 7:10 PM, nursing documented that the patient was "lethargic"and that she responded to painful stimuli. The patient's mother provided the medical history. At 7:33 PM, the ED physician documented that the patient was "obtunded and poorly responsive" and "unable to walk even with assistance". The patient remained in the ED until 8:26 PM and then she was discharged to home.

There were no additional nursing assessments documented. There were no additional assessments documented by medical staff. Upon discharge, the ED physician documented that patient was "stable".