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ST MARY MEDICAL CENTER 18300 HIGHWAY 18 APPLE VALLEY, CA 92307 Nov. 25, 2014
VIOLATION: EMERGENCY ROOM LOG Tag No: A2405
Based on record review and interviews, the hospital failed to maintain and update Emergency Department (ED) central logs to include the reason why patients' went to the ED, from June 1, 2014 through June 3, 2014. This failure had the potential to affect the quality of care provided in the ED, and the potential to create a possible delay in treatment, adversely affecting patients' health and safety.

Findings:

During a record review of the ED logs for June 2014, it was noted that the ED log were not completed for June 1, 2, and 3, 2014.

a. The ED logs for June 1, 2014, did not include the reason for the ED visit for 22 patients who went into the ED on that date. For 7 of the 22 patients, the ED log did not include the reason for the visit or a final medical impression of their condition before they were discharged from the ED and/or left the ED without being seen or against medical advise.

b. The ED logs for June 2, 2014, did not include the reason for the ED visit for 139 patients who went into the ED on that date. For 11 of the 139 patients, the ED log did not include the reason for the visit or a final medical impression of their condition before they were discharged and/or left the ED without being seen or against medical advise.

c. The ED logs for June 3, 2014, did not include the reason for the ED visit for 40 patients who went into the ED on that date. For 4 of the 40 patients, the ED log did not include the reason for the visit or a final medical impression of their condition before they were discharged from the ED.

During an interview on November 25, 2014, at 9:25 AM, the Manager of Accreditation Readiness acknowledged the missing data on the ED logs and confirmed that the logs were not updated to include the missing information for the patients. The Manager of Accreditation Readiness then stated that the missing information on the ED logs for June 1, 2, and 3, 2014 would have to have been filled in manually because their computer system was down on those dates. The Manager of Accreditation Readiness also stated that once the computer system was up, it did not allow them to go back into the system to add the missing information.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
Based on interview and record review, the facility failed to ensure that a timely medical screening examination to determine if an emergency medical condition existed for 3 of 40 sampled patients (Patients 16, 28 and 30) was completed. This failure had the potential to affect the patients' health and safety by not providing medical treatment for an emergency medical condition.

Findings:

1. During a record review on November 24, 2014, of Patient 16's emergency Department (ED) record it was noted that the patient arrived at the ED on June 26, 2014, at 10:51 PM. Patient 16 was 7 weeks pregnant and complained of having pelvic pain and light spotting (vaginal bleeding). The face sheet of the medical record for Patient 16 noted under insurance coverage that the patient was a self-pay.

Further record review for Patient 16 notes that on June 26, 2014, at 1:20 AM, the patient was seen by a Registered Nurse (RN). Her vital signs were within normal ranges. Her pain level at that time was a 6 (the pain scale ranges from 0 through 10, with 10 the highest level of pain). She was assessed as a priority 3 (semi) urgent care level. (Patient acuity levels are classified as : level 1 emergent, level 2 urgent, level 3 semi urgent, level 4 less urgent, and level 5 non urgent).

During an interview with RN 1 on November 25, 2014, at 9:45 AM, RN 1 confirmed there was no documentation in the ED record to show that Patient 16 was assessed by a physician during her ED visit to the hospital on June 26, 2014.

During a tour of the ED on November 25, 2014, at 9:30 AM, the Manager of the ED, stated that there was only one physician and one physician assistant assigned to cover the 42 bed ED between the hours of 2:00 AM and 6:00 AM.

During further record review of Patient 16's ED visit, for June 26, 2014, noted that Patient 16 left without being seen (LWBS-without a medical screening examination) at 6:29 AM. The final notation of Patient 16's visit to the ED, notes the "Primary Impression: Patient left without being seen. Secondary Impressions: (blank). Disposition: Left W/O (without) triage (a quick assessment by the RN to determine severity of the patient's condition). Condition: undetermined."

Patient 16 went to the ED department at 10:51 AM, on June 26, 2014, and by 6:29 AM (7 hours and 38 minutes) was not seen by a physician. The RN documented at 6:29 AM "Pt. (patient) states she does not want to wait anymore." During the 7 hours and 38 minutes period that Patient 16 was in the ED, the patient was not given a full head to toe assessment by a nurse and was not medically screened by a physician.






2. During a record review on November 24, 2014, of Patient 28's ED record it was noted that the patient had arrived at the ED on June 10, 2014, at 00:31 AM. Patient 28 complained of dizziness, vomiting and running a fever for 1 day. The face sheet of the medical record for Patient 28, also noted under insurance coverage that the patient was a self-pay.

Further record review for Patient 28 noted that on June 10, 2014, at 1:05 AM, the patient was seen by a RN. The patient's body temperature was 97.4 at the time. His pain level at that time was a 5 (the pain scale ranges from 0 though 10, with 10 the highest level of pain). The signs and symptoms of his illness, as noted by the RN, were diarrhea,and influenza like illness. He was assessed as a priority 3 (semi) urgent care level; (Patient acuity levels are classified as : level 1 emergent, level 2 urgent, level 3 semi urgent, level 4 less urgent, and level 5 non urgent).

During the medical record review, on November 24, 2014, at 10:30 AM, the Manager of Accreditation Readiness confirmed there was no documentation in the medical record to show that physician had assessed Patient 28 during his ED visit to the hospital on June 10, 2014.

During a tour of the ED on November 25, 2014, at 9:30 AM, the Manager of the ED, stated that there was only one physician and one physician assistant assigned to cover the 42 bed ED between the hours of 2:00 AM and 6:00 AM.

During further record review of Patient 28's ED visit, for June 10, 2014, noted that Patient 28 was called by the nurse at 6:10 AM, 6:28 AM and 6:45 AM, (5 hours and 39 minutes after arriving to the ED) so the patient could be seen by the physician (with no response). The final notation of Patient 28's visit to the ED, noted the "Primary Impression: Patient left before triage assessment. Secondary Impressions: (blank). Disposition: Left W/O (without) being seen by the physician. Condition: undetermined."

Patient 28 went to the ED department at 00:31 AM, on June 10, 2014, but had not been seen by 6:10 AM, when the hospital first noted the patient to be missing. During the 5 hours and 39 minutes period that Patient 28 was in the ED, the patient was not given a full head to toe assessment, and the hospital had not completed a medical history. In addition there was no documentation in the medical record to show that a physician performed a medical screen examination on Patient 28.

3. During a record review on November 24, 2014, of Patient 31's ED record it was noted that the patient arrived at the ED on July 8, 2014, at 00:59 AM. Patient 31, was taken to the ED by her mother who stated the reason for her visit was the patient fell off the couch and hit the back of her head on the table. The face sheet of the medical record for Patient 31, also noted under insurance coverage that the patient was a self-pay.

Further record review for Patient 31 noted that on July 8, 2014, at 2:33 AM, the patient was seen by a RN. Patient 31 was assessed as a priority 3 (semi) urgent care level.

During the medical record review, on November 24, 2014, at 10:50 AM, the Manager of Accreditation Readiness confirmed there was no documentation by the physician, to show the physician assessed Patient 31 during her ED visit to the hospital on July 8, 2014.

During a tour of the ED on November 25, 2014, at 9:30 AM, the Manager of the ED, stated that there was only one physician and one physician assistance assigned to cover the 42 bed ED between the hours of 2:00 AM and 6:00 AM.

The record review for Patient 31's next entry documented for July 8, 2014, noted Patient 31 was called by the nurse at 6:17 AM, 7:00 AM and 8:02 AM, (5 hours and 18 minutes after arriving to the ED) so the patient could be seen by the physician (with no answer). The final notation of Patient 31's visit to the ED, noted the "Primary Impression: Patient left without being seen. Secondary Impressions: (blank). Disposition: Left W/O (without) triage (the initial RN quick assessment of a patient). Condition: undetermined."

Patient 31 went to the ED department at 00:59 AM, on July 8, 2014, but had not been seen by 6:17 AM, when the hospital first noted the patient to be missing. During the 5 hours and 18 minutes period that Patient 31 was in the ED, the patient was not given a full head to toe assessment, and there was no assessment of the patient's complaint of a head injury. In addition there was no documentation in the medical record to show that a physician performed a medical screen examination on Patient 31.