The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HOLMES REGIONAL MEDICAL CENTER 1350 S HICKORY ST MELBOURNE, FL 32901 Oct. 22, 2011
VIOLATION: FORM AND RETENTION OF RECORDS Tag No: A0438
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and a review of facility documentation in the form of filmed footage, the facility failed to ensure that medical records were accurately written with respect to when the patient first presented to the emergency room in one of twenty-four sampled patients (#1).

Findings:

A review of facility policy "Admission of Patients to the Emergency Department" was performed. It read: A medical record will be initiated on all patients that present for treatment at the ED (Emergency Department). The record will include information for patient identification, consent for treatment, and documentation of the care that was rendered."

An interview conducted with the Director of Emergency Services (along with the Director Quality and Risk Manager) on 10/21/11 at 1:19 PM revealed the following information regarding the presentation of #1 and her husband to the facility on [DATE]. She stated that the patient's husband drove up to the emergency room door. The husband then came in and told a Registered Nurse that his wife was pregnant, in the car outside, and having complications. He stated that she was 7 ? months pregnant. The nurse told the husband that since she was 7 ? months pregnant, she needed to go to labor and delivery. The nurse then gave the husband directions on how to get there. The Director of Emergency Services stated during the interview that Labor & Delivery was on the opposite side of the building. The husband left the emergency room , went out to his car and drove around the building. Next, he drove up to the outpatient entrance which is directly across from the Labor & Delivery entrance by approximately 40 feet. He then left the car and went into the Outpatient entrance seeking help. After some delay, the patient was brought into the hospital by a Code team, which took her to the emergency room .

A review of video of the preceding was performed on 10/21/11 at approximately 2:00 PM. The video had time signatures. The following events took place at the approximate stated times:
12:09:40 Car arrives in ER driveway
12:09:52 The husband is at the ER reception desk. At this time he engages in a discussion with the RN, with the paramedic watching.
12:10:29 The husband leaves the nurse.
12:10:42 The patient drives away
12:12:19 The husband arrives at the Outpatient driveway.
12:12:45 The husband is out of the car.
12:13:05 The Registration Clerk and volunteer head out to the car.
12:13:43 The Registration Clerk and the Volunteer are back inside.
12:13:54 The volunteer is out to the car.
12:14:00. The volunteer is back in.
12:15:13 The volunteer leaves
12:15:48 The EKG tech goes out to the car
12:16:00 The supervisor is seen waiting for the code responders
12:16:37 The Code team arrives.
12:17:25 #1 is placed on a gurney.
12:17:58 A code cart is observed.
12:18:22 The patient is brought into the hospital.

The preceding findings from video were generally consistent with the findings from the interview with the Director of Emergency Department as mentioned above.

A review of the medical record of #1 was performed. There was no documentation in the medical record of the patient's initial presentation to the emergency room as discussed in the interview, above. The Emergency Physician Record indicated that #1 was in the emergency room at 12:20 PM. The "ED (Emergency Department) Triage Document" indicated time of triage at 12:21 PM. The first of these two times was approximately 10 minutes after the patient had first approached staff in the emergency room . This entry was by a Registered Nurse. Per the above interview of Director of the Emergency Department at the above stated time, the time of initial presentation of #1 to the emergency room was prior to 12:20 PM and was reflected in video review (12:09 PM). The 12:20 PM time as noted in the medical record of #1 was after the patient had arrived at the entrance to Labor & Delivery, on the other side of the building. This constitutes an inaccurate and incomplete medical record.

The preceding findings were confirmed during an interview of the Risk Manager, Quality Director and Emergency Department Director at approximately 5:15 PM on 10/21/11.