HospitalInspections.org

Based on document review and staff interview, the facility failed to follow its policy for patients seeking emergency care and failed to develop a transfer policy.

Findings include:

1. Facility policy #2.11 titled "Emergency Care" developed 6/11/09 and last reviewed/revised 11/22/11 (The only revision was on code blue emergency call) states under policy on page 1: "....or any individual who presents to (facility #1) requesting emergency medical treatment will be assessed, provided initial treatment, provided referral when appropriate, admitted to the hospital, and/or stabilized and transferred if necessary." Page 2 states the following under procedure: "If an individual at (facility #1) develops an emergency medical condition, or an individual presents to (facility #1) with an emergency medical condition:
1. Any hospital personnel who becomes aware of the emergency will contact the ICU Charge Nurse to immediately respond to the patient. If the emergency is life threatening, the individual will be taken to ICU for complete assessment/treatment. If the individual presents to the hospital seeking treatment, the individual will be taken to a telemetry room for immediate assessment. 2.A registered Nurse will assess the patient's medical condition and begin initial emergency treatment to stabilize the patient............
6. Document all appraisals, interventions and outcomes. For inpatients, documentation should occur in the patient's medical record. For all other individuals, document on a downtime documentation form and attach to a completed Incident Report .........................." The policy did not address procedure for transfer.

2. An assessment form (narrative section) was completed for patient #1 dated 11//11. The exact date, time of the visit, and the patient's name was not on the form. There was no incident report completed for his/her visit.

3. Patient #3 was listed on the registration log as a walk-in at 1:34 p.m. on 11/19/11, however there was no assessment form for the patient and no evidence that the patient was assessed per policy. Additionally, there was no incident report form completed for the visit.

4. Patient #4 was listed on the log as a walk-in at 6:04 p.m. on 12/31/11 and was treated and released. There was no incident report completed for the visit.

5. Patient #5 was listed on the log as a walk-in at 1:10 a.m. on 2/2/12 was assessed and admitted. There was no incident report completed for the visit.

6. Staff member #2 indicated the following in interview beginning at 11:10 a.m.:
(A) He/she verified there was no assessment form completed for patient #3. It could not be determined why an assessment form was not completed. The nurse involved is no longer at the facility.
(B) He/she indicated that the "downtime documentation form" referenced in policy #2.11 would be the Walk-in/Emergency Patient Assessment Form.
(C) He/she verified there were no incident reports completed for patients #1, 3, 4, and 5.
(D) He/she verified that patient #1 arrived at the facility in November and was transferred to facility #2.
(E) He/she indicated the facility has a transfer protocol but no policy.

7. RN #1 indicated the following in phone interview at 12:40 p.m.:
(A) He/she indicated that they did not fill out an assessment form for patient #1, however stated we "have one now" The staff member indicated that he/she did not know when it was filled out and he/she was not the one who filled it out.
(B) He/she was involved in the treatment of patient #1.