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FAXTON-ST LUKE'S HEALTHCARE 1656 CHAMPLIN AVENUE UTICA, NY 13503 June 22, 2017
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on findings from medical record (MR) review and interview, the emergency department (ED) did not ensure that emergency care was provided in accordance with generally accepted standards. Specifically, 1) in 1 of 10 MRs, an ED Attending Physician did not ensure that a physical evaluation of a patient was documented in the MR, 2) in 2 of 10 MRs, nursing staff did not document patient assessments and the ED lacked a policy and procedure (P&P) that addressed patient assessment by nursing staff, and 3) in 3 of 10 MRs, nursing staff did not document patient vital signs at the time of discharge. This could cause staff to have lack of awareness a patient was unstable.

Findings regarding (1) include:

-- Review of Patient #1's MR revealed that he (MDS) dated [DATE] at 11:36 pm with complaints of back pain, numbness in both legs, and shortness of breath. He was assigned a triage level 3 (on 1-5 level acuity scale with 1 being the most acute). Vital signs obtained at 11:43 pm revealed blood pressure (BP) 134/85, pulse (P) 115, oxygen saturation (O2 Sat) on room air 99%, respirations (R) 17 and temperature (T) 36.6 degrees Celsius. At 12:08 am (5/10/17) Staff A (ED Nurse Practitioner (NP)) evaluated the patient and documented: The patient's presenting symptoms were moderate stiffness to the lumbar back. The patient denied any fall, and stated he stepped wrong and almost fell . The patient had a recent infection of cellulitis. A review of all systems was negative except for back pain and stiffness. An EKG and laboratory work were completed. EKG revealed sinus tachycardia. Laboratory results were all within normal limits apart from the C-reactive Protein (CRP), which was elevated at 49.4 mg/L (normal range is 0.0-5.0 mg/L). At 2:57 am, Staff A documented the ED Attending Physician had examined the patient.

-- Per interview of Staff A on 6/22/17 at 12:00 pm, he/she requested the ED physician assistance regrading what type of CT scan to order.

-- Per interview of Staff B (ED Attending Physician) on 6/21/17 at 11:40 am, he/she examined Patient #1 and didn't need to document a completed assessment because he/she agreed with Staff A (ED NP)'s assessment of the patient. He/she stated the patient had no history of pulmonary embolism, was hemodynamically stable, neurovascular system intact, pulses were positive, no fever, no discoloration of the legs and the patient complained more about back pain. He/she spoke to patient and told him a CT scan of the lower back was not required.

There was no documentation by the ED Attending Physician in the MR of a physical examination of the patient.

-- Per interview of Staff C (Medical Director) on 6/21/17 at 12:15 pm, he/she acknowledged the lack of a documented assessment of the patient by the ED Attending Physician.

Findings regarding (2) include:

-- Review of Patient #1's MR revealed he (MDS) dated [DATE] at 11:36 pm with complaints of back pain, numbness in both legs, and shortness of breath. The patient was triaged at 11:43 pm and revealed the patient had a recent cellulitis. (location not documented) Patient #1 was discharged from the ED on 5/10/17 at 2:18 am. There was no documentation indicating that nursing staff performed a physical assessment of the patient that focused on the patient's presenting complaint.

-- Review of Patient #2's MR revealed he (MDS) dated [DATE] at 1:25 am with recent seizure activity. The patient was triaged at 1:51 am and revealed the patient had no medical or surgical history. Patient #2 was discharged from the ED to home at 3:59 am. There was no documentation indicating that nursing staff performed a physical assessment of the patient that focused on the patient's presenting complaint.

-- During interview of Staff D (ED Nurse Manager) on 6/22/17 at 2:15 PM, he/she acknowledged the lack of hospital P&P addressing nursing assessments (including vital signs) in the ED. He/she stated that every patient should have a focused assessment that includes the chief complaint, allergies, pain, fall risk, social history, and nursing diagnosis. It is expected the RN will complete nursing assessments and vital signs based on clinical judgement. He/she acknowledged the lack of nursing assessment in the above MRs.

Findings regarding (3) include:

-- Review of Patient #2's MR revealed he (MDS) dated [DATE] at 1:25 am with recent seizure activity, was triaged at 1:51 am, and vitals were completed. Patient #2 was discharged at 3:59 am with a temperature (T) of 98.7 degrees Fahrenheit and pain level of 0. There was no documentation that a complete set of vital signs were obtained prior to discharge.

-- Review of Patient #3's MR revealed she (MDS) dated [DATE] at 5:26 am with right sided facial pain, was triaged at 5:31 am, and vitals were completed. Patient #3 was discharged at 10:51 am. There was no documentation of a complete set of vitals prior to discharge.

-- Review of Patient #4's MR revealed he (MDS) dated [DATE] at 10:37 pm with right leg numbness and pressure in the head, was triaged at 10:42 pm, and vitals were completed. Patient #4 was discharged on [DATE] at 1:54 am. There was no documentation of a complete set of vitals prior to discharge.

-- Per interview of Staff D on 6/22/17 at 3:10 pm, the above findings were acknowledged.