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.

LAUREL REGIONAL MEDICAL CENTER 7300 VAN DUSEN ROAD LAUREL, MD 20707 June 11, 2012
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

In 1 out of 20 medical records selected from the Emergency Department log, there was no evidence that the "Important Message (IM)" was provided to the patient for the 5/1/12 admission.

Patient #12 is a [AGE] year old male who presented to the Emergency Department at Laurel Regional Hospital with complaint of chest pain and nausea on 5/1/12. The patient was registered and triaged at 3:45 pm as ESI 2, had EKG performed at 4:05 pm and seen by the physician at 4:22pm. The patient was admitted to the hospital on 3:05 am on 5/2/12. The Important Message from Medicare found in the medical record was dated 4/16/12, which was the IM from the patient's previous admission not the current admission. Hospital staff were unable to validate that the patient received his Important Message for the 5/1/12 admission.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the patient's medical records from Laurel Regioanl Medical Center and the hospital that subsequently provided care to his hand injury it was determine that the hospital failed to meet the emergency needs of patient #1 as evidenced by:


Patient #1 is a [AGE] year old male who arrived at the Laurel Regional Hospital's Emergency Department (ED) on May 26, 2012 at 2:30 pm with a chief complaint of laceration to the 4th and 5th digits of the right hand. Patient # 1 also complained of numbness, bleeding and throbbing pain to the area at a severity level of 9 on a scale of 1 to 10, with 10 being severe. Patient #1 was placed into a fast track room at 2:50 pm and a nursing assessment was completed.

Based on review of the medical record it was determined that at 3:10 pm, Patient #1 was seen by the ED Physician Assistant (PA) and a screening examination was initiated. On review of documentation under the medical screening examination specifically the procedures section, documentation indicates that the PA performed a sterile prep and attempted to inject Patient #1 for a digit block. However, on further review of the medical record there is no documentation that the PA explained the steps of the procedure, including the need to administer an injection, prior to injecting Patient #1 for the digit block.

According to the PA's procedure note, at the time Patient #1was given the injection he pushed the PA causing the PA to be stuck by the needle that had been used to inject him. Further review of the documentation indicates that the PA then informed Patient #1 not to move but at that time Patient #1 got up screaming and informed the PA that he was going to another hospital.


The PA subsequently documented that Patient #1 left against medical advice (AMA). However, there is no documentation by the PA that she attempted to counsel Patient #1 regarding the need for further medical follow-up, informed him of the risk of discontinuing medical treatment, offered to cover the open wound, had offered to assist in transfer to another hospital, or attempted to provide the usual leaving against medical advice (AMA) form to Patient # 1 prior to his leaving the ED.


The AMA form is a document, which certifies that the patient is refusing care at their own insistence and without the authority of and against the advice of the attending physician or in this case the PA. In addition, the AMA form is also a means of documenting that the medical risks/benefits have been explained to the patient by a member of the medical staff and that the patient understands those risks.


Although an AMA form had not been used to document this information, the same information could have been documented in the ED record. However, review of the medical record is void of any documentation that the PA explained to Patient #1 medical risks and benefits prior to his leaving the ED.


A nursing entry made by the attending RN states that Patient #1 refused to be medically advised but also lacks documentation of what advice was attempted such as risk, benefits, or that if Patient #1 was dissatisfied with care, staff could assist him in transfer to another hospital. Patient #1 subsequently left the ED to seek medical treatment at another hospital.


On further investigation and review of the medical record obtained from Hospital #2 where Patient #1 went to seek medical care, it was determined that Patient #1 arrived at the ED of Hospital #2 at 4:36 pm with a chief complaint of a deep cut to the fingers, bleeding, numbness, inability to move his fingers, and pain. Patient #1 was triaged and received a nursing assessment at 4:42 pm.


A medical screening/examination was initiated at 7:32 pm by the ED Physician Assistant (PA). At the time of the medical screening the practitioner assessed Patient #1with a laceration to the right 4th and 5th digits with inability to bend both digits. After completion of the medical examination the PA determined that Patient #1 had evidence of tendon laceration with concern for nerve or arterial laceration which would require surgery.


X-rays were completed and no acute fracture or dislocation was identified. Patient #1 was medicated for pain and the PA determined that Patient #1 would require specialized services at another hospital. Documentation indicates that a call was subsequently placed to the on-call physician at Hospital #3 to initiate transfer for Patient #1. Patient #1 was informed of the findings, instructions were reviewed with Patient #1 and he was informed that he was to go directly to the ED at Hospital #3.


Patient #1 arrived to the ED of Hospital #3 at 11:36 pm with a diagnosis of Flexor Tendon Injury of the right hand. He was immediately triaged, assigned an urgent level of care and placed in an examination room. A nursing assessment was completed, intravenous access was initiated and blood was drawn for pre-operative laboratory studies. Patient#1 was subsequently seen and evaluated by the hand surgery on-call resident who determined that Patient #1 had a right small finger, ring finger laceration with possible small finger flexor digitorum profundus tendon transection. The flexor digitorum profundus flexes the fingers and is innervated by the ulnar and median nerve. Patient #1 was admitted and made NPO (nothing by mouth) for surgery.


On further review of the medical record, it was determined that on the morning of May 27, 2012 after discussing the risk, benefits, alternatives, and the procedure in detail with Patient #1 consent for surgery was obtained and Patient #1 was taken to the OR where irrigation, debridement and repair of the flexor digitorum profundus tendon, zone II and flexor digitorum sublimis tendon, zone II were repaired. Flexor tendon injuries are classified using zones of the hand. The zone of injury usually influences the method of repair. Documentation indicates that patient #1 tolerated the procedure very well and was monitored throughout the day. Later that evening Patient #1 was discharged home with instructions to continue antibiotic therapy, pain medications and to follow-up with the hand surgeon in 5 days.
VIOLATION: UNUSABLE DRUGS NOT USED Tag No: A0505
At the time of the on-site investigation and tour of the ED, a visual inspection of the Omnicell medication storage unit on the A side of the ED and it was observed that open multi-dose vial of regular insulin that had not been labeled as required by the hospital's policy.

Based on current standards for labeling of multi-dose medication vials it is recommended that Multi-dose vials are to be discarded 28 days after their first use, unless the manufacturer specifies otherwise. Once the vial cap is removed or the vial is punctured with a needle, the manufacturer's expiration date is no longer valid, and a revised date needs to be determined. The only exceptions are vaccines, for which the Centers for Disease Control (CDC) allows the use of the manufacturer's expiration date.

At the time of finding the unlabeled insulin, the surveyor queried the RN in regards to the hospital's policy on labeling multi-dose medication vials. At that time it was determined that the hospital's policy on medication managementrequires all multi-dose vials to be labeled with the date opened and the initials of the healthcare professional to be placed on the label. The policy also requires that opened vials are to be discarded within twenty-eight (28) days unless otherwise specified by the manufacturer. This requirement was not met at the time of the surveyor's inspection of the medication storage unit.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of the medical records it was determined that the hospital failed to make legible entries in the records, failed to time entries into the record and failed to document the patient's disposition as evidenced by:


In 3 out of 20 medical records selected from the hospital Emergency Department log, the hospital failed to ensure the medical screening examination was timed by the provider.


Patient #2 is a [AGE] year old male who presented to the Emergency Department at Laurel Regional hospital on [DATE] with complaint of ringing in the ears, lost of balance dizzy, left eye pain since early morning. The patient was triaged by nursing at 3:10 pm but on the medical screening examination form in the block for time seen, the provider wrote the date.


Patient #16 is a [AGE] year old male who present to the Emergency Department at Laurel Regional hospital on [DATE] with complaint of headache and face trauma. The patient was involved in an altercation and kicked in the face and head. The patient was triaged at 3:44pm but on the medical screening examination form in the block for time seen, the provider failed to write the time, the block is blank.


Patient #17 is an [AGE] year old female who presented to the hospital ED at Laurel Regional hospital on [DATE] with altered mental status and abnormal movements of the extremities. The patient was triaged by the nurse at 1:46 pm but on the medical screening examination form in the block for time seen, the provider failed to write the time, the block is blank.


In 3 out 20 medical records selected from the hospital emergency department log, the hospital failed to document the patient's discharge/transfer.


Patient #3 is a [AGE] year old female who presented to the Emergency Department at Laurel Regional hospital on [DATE] with complaint of chest pain. The patient was registered at 9:34pm, triaged at 9:45 pm as an ESI 3, and placed in a bed in the main ED at 9:53 pm. The patient had an EKG at 9:48 pm which revealed normal sinus rhythm. The patient left the ED without being seen by the physician. There are no documented notes in the medical record regarding why the patient left the ED. The patient signed an Against Medical Advice form on 4/1/12 at 10:05 pm. The form indicates that the risk for leaving the hospital were discussed with the patient and treatment alternatives but the physician was not checked off as notified and the reason for leaving was not completed. The patient's condition was checked off as good. There was no documented description of patient's condition at discharge nor was the physician notified.


Patient #6 is a [AGE] year old patient who presented to the Emergency Department at Laurel Regional hospital on [DATE] with complaint of a fall at home. The patient ' s blood sugar was greater than 400 and positive for nausea, vomiting and diarrhea x 5 days. Patient had a positive nares deformity, unable to see septal hematoma. The patient registered at 11:04 am, triaged by the nurse at 11:00am as ESI 4 and evaluated by the physician at 11:50 am.

The patient was worked-up for cardiac due to a complaint of chest pain and was given a CT scan of the head and face. The patient's EKG was abnormal and per the progress note the patient was given aspirin, monitored and awaiting transport to another area hospital. The patient transfer form was not in the medical record. The hospital staff feels that the entire form was sent without removing the carbon for placement on the chart. This transfer form discuss the reason for transfer, risk and benefits for transfer, informed consent, vital signs and check list to ensure appropriate documentation was sent with patient including the type of transport and acceptance information for the receiving hospital.


Patient #8 is a 2 year old female who was brought to the Emergency Department at Laurel Regional Hospital by her mother on 5/1/12 for complaint of lower lip swelling and rash to neck. The rash was clearing, child active and no shortness of breath. The patient was registered at 8:50 pm, triaged by the nurse as ESI 4 at 9:05 pm, and sent to Fast Track. The chart is void of any further documentation. There are no progress notes regarding the patient. At the top of the triage sheet is written LWOT (Left Without Treatment) 10:30 pm and 10:50 pm, which per the hospital staff documents that the staff called for the patient during these times but no one responded and it appeared the mother left the ED.


In 2 of 20 medical records selected from the Emergency Department log, revealed illegible handwriting.


Patient #19 is a [AGE] year old male who presented to the Emergency Department at Laurel Regional hospital on [DATE] for aggressive behavior and wandering into traffic. The patient was suspected to be under the influence of drugs. The medical screening examination form is illegible. The time seen, provider's name, chief complaint and the comment section under the physical examination section was also illegible. The risk for errors due to illegible handwriting is clearly documented.