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BRATTLEBORO MEMORIAL HOSPITAL 17 BELMONT AVE BRATTLEBORO, VT 05301 June 1, 2011
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on record review and confirmed through staff interview the facility failed to assure the medical record contained sufficient documentation to support the decision for disposition for 3 of 17 patients who presented to the Emergency Department (ED) for care and services. (Patients #2, #8 and #12). Findings include:

Per record review, conducted on 5/31/11 and 6/1/11, the medical records for Patients #2, #8 and #12 were lacking documentation of a full physical examination conducted during ED visits for each of the respective patients.

1). Patient #12 was transported to the ED by police, at 12:40 AM on 2/22/11, "here for PC (police custody) screening" per the Emergency Nursing Record, which also noted the alcohol level as, " 0.235 alcosensor". The Emergency Physician Record identified the chief complaint as "Intoxicated"...."brought in by police". Ethanol Intoxication was identified under clinical impression and although a physician note stated, "medically cleared, discharged to police custody" the Physical Exam was not completed, and lacked documentation of assessment of the respiratory system, cardiovascular system, abdomen, skin and extremities.

2). Patient #2, who was seen in the ED on 3/24/11, had a chief complaint of, "depression", "ETOH abuse brought in by police after pointing a gun to his head, more of a gesture, he didn't mean it", per the Emergency Physician Record. Although an alcohol level and other lab studies were obtained, and despite the fact that the physical exam was lacking assessment of the head, neck, respiratory system, cardiovascular system, abdomen, skin and extremities, the physician identified that the patient was medically cleared for psych referral. The psych evaluation, "assessment for suicidal ideation and depression", was conducted and the patient was ultimately discharged to home, after refusing inpatient treatment.

3). Patient #8 was transported by law enforcement, to the ED, at 8:37 PM on the evening of 5/21/11, with a chief complaint, as documented in the Emergency Nursing Record, of ; ETOH (alcohol) today - "found down on street, difficult to arouse". The Emergency Physician Record revealed that although a physical exam had been partially completed, which identified that the patient had a depressed mood/affect and abnormal, "wide gait", the portion of the exam that addressed the patient's 'General Appearance' and level of distress was not completed. There were no diagnostic studies, including alcohol level, completed. The clinical impression was listed as Ethanol Intoxication, the patient received an oral medication for nausea and was discharged , at 10:10 PM, per Discharge Order: "The patient has not shown functional capacity, but Patient can be discharged in the care of a responsible adult."

During interview, at 9:53 AM on 6/1/11, the Medical Chief of ED Services confirmed the lack of documentation of complete physical exam for Patients #2, #8 and #12 during their respective ED visits and stated that they should have been completed by the responsible provider.