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BAPTIST MEDICAL CENTER 111 DALLAS STREET SAN ANTONIO, TX 78205 Feb. 2, 2011
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on review of medical records, review of policies and interviews it was observed that there were emergency medical records that were not complete, timed and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided. This requirement was not met as follows.

Findings:

a. In review of 20 emergency medical records (MR #1-20) it was discovered that 7 out of the 20 medical records (35%) reviewed (MR #5, 6, 8, 9, 11, 19 and MR #20), did not have risk assessments for homicides/suicides ideations for patient who came in with anxiety marked "N/A" for non-applicable. There were 9 out of 20 emergency medical records (45%) (MR #3, 6, 8, 11, 12, 13, 14, 15 and MR #17) that did not document if an emergency medical condition did or did not exist.

b. Reviewed Baptist Health System policy titled "Psychiatric Patients in the Emergency Department" NURS-ED-10, effective date July 2008 with last revision on 10/02. The Main purpose was to provide guidelines for assessment, monitoring, and safety of psychiatric patients in the Emergency Department (ED). The policy calls for "all" patients presenting to any Baptist Health System ED will be triaged/screened by a registered nurse as soon as possible. Patients presenting with a primary complaint of an emotional or behavioral disorder will be assessed for risk of suicide and or homicidal behavior." If patient answers "yes" or "no" then the staff member has to complete an additional screening tool to further probe the possible risks and features of the behavior.
The Facility failed to follow this policy by not completing this Baptist Health System Potential Homicide Risk Screening Tool or the Baptist Health System Potential Suicide Risk Screening Tool. If patients responded that they did not have suicidal or homicidal ideations nurses would choose to mark on this screen non-applicable "NA" to perform these assessments therefore not completing these forms.

c. Interviewed staff #11 emergency room (ER) nurse at 2:40 pm on February 1, 2011 via telephone. When asked about the risk assessment to determine if a patient is suicidal or homicidal she said usually when a person comes in for an emotional or behavioral problem she willl only ask the first five questions on the risk assessment. If the patient states they "are not" suicidal or homicidal she will usually stops right there and will mark non-applicable for the assessment. Interviewed staff #2, Baptist Health System Regional Risk Manager at 2:00pm on February 1, 2011 in the administration conference room. Staff #2 reviewed emergency records before the department state health services onsite investigation said that in her review of emergency medical records she also observed that the nurses were marking "non-applicable" on these assessments if the patient responded that they were not suicidal or homicidal. She acknowledge by policy the emergency nurses should complete in full these assessments for the patients who visits for an emotional and/or psychiatric disorder regardless of if state that they "are" or "are not" suicidal or homicidal. She said retraining will be done with the emergency room staff on completing this form and completion of the form will be monitored. Staff #2 also confirmed that the emergency room physicians should be marking the presence or absence of an emergency medical condition on their physician review sheets after an appropriate medical screen is conducted. She acknowledges this form was incomplete. Staff interview could not show that this requirement was met.