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.
|ADVENTHEALTH SEBRING||4200 SUN N LAKE BLVD SEBRING, FL 33872||May 13, 2011|
|VIOLATION: EMERGENCY SERVICES POLICIES||Tag No: A1104|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, policy review and staff interview it was determined that the facility failed to ensure that the policy regarding patient discharge from the Emergency Department (ED) was followed for 3 (#1, #5, #6) of 10 sampled patients. This practice does not ensure a safe discharge.
The facility's policy "Discharge from the Emergency Department" #ER , last reviewed 8/10 required that a complete set of vital signs be obtained prior to discharge. In addition, patients who are chemically impaired are to be assessed for level of consciousness at the time of discharge.
1. Patient #1 (MDS) dated [DATE]. He received a medical screening examination and was diagnosed with seizure disorder, anxiety and alcohol intoxication. The patient's blood alcohol was 458. The physician noted that the patient was stable and ready for discharge at approximately 9:00 p.m. The patient remained in the ED until approximately 12:30 a.m. on 4/3/11. The medical record revealed that the patient's healthcare surrogate took the patient home. A repeat blood alcohol at 11:30 p.m. revealed the level was still elevated at 311. Review of nursing documentation at the time of discharge revealed only the temperature was assessed. There was no documentation of the other vital signs and no documentation of the patient's level of consciousness.
The ED nurse manager was interviewed on 5/13/11 at approximately 10:00 a.m. She stated that the patient remained in the ED until 12:30 a.m. in order to receive the intravenous fluids that were ordered and had to wait until the healthcare surrogate arrived to take him home.
2. Patient #5 (MDS) dated [DATE] at approximately 9:17 p.m. with the chief complaint of weakness. The patient received a medical screening examination and was determined to be stable for discharge by the physician at 12:40 a.m. on 4/6/11. Review of nursing documentation revealed the patient's blood pressure was not recorded at the time of discharge as required by the facility's policy.
3. Patient #6 (MDS) dated [DATE] with the chief complaint of change in mental status. The patient received a medical screening examination and was discharged at 1:59 p.m. Review of nursing documentation revealed the the nurse documented only the patient's temperature.
The nurse manager who was present during the record reviews on 5/13/11 confirmed the above findings.