HospitalInspections.org

1. Based on reviews of clinical records and staff interviews Frio Regional Hospital failed to include in the medical record a description of a medical screening examination conducted by an authorized physician to determine if a medical emergency existed.
The findings included:
a. A review of clinical record #20 conducted on 3/28/12 at 1:30 p.m. in the emergency department revealed a triage and nursing assessment had been performed by the nursing staff, a medical screening disposition form indicating the physician had conducted a screening and determined the patient did not have a condition that constituted a medical emergency however there was no evidence the physician on duty actually conducted a medical screening examination utilizing the hospital's designated "Emergency Department Physician Record". Staff # 2, following her own review of the findings and verifying no lost or misplaced documents with the emergency department staff and director of medical records she acknowledged the physician's medical screening examination was not a part of the record and she could not provide any evidence one had been conducted on the patient.
b. Interviews conducted with staff members # 2 and # 3 conducted on 3/28/12 at 2:00 p.m. in the emergency department following their own review of the record they acknowledged the hospital's policy and procedures were not followed that required emergency room physicians to document a medical screening examination on the designated form "Frio Regional Hospital Emergency Department Physician Record" and to circle A if a patient has a medical emergency that requires immediate stabilization and treatment or B that a patient does not have a medical emergency that requires immediate stabilization and treatment on the document "Frio Regional Hospital Emergency Department Emergency Medical Screening Exam Disposition".