HospitalInspections.org

Based on review of facility documents, medical records (MR), and staff interview, it was determined the facility failed to ensure the Emergency Department (ED) patient was reassessed at least every two hours for one of 11 ED medical records reviewed (MR1); failed to ensure pediatric patients presenting to the ED were seen by the ED physician for two of 11 ED medical records reviewed (MR7 and MR8); and failed to ensure pregnant women 20 weeks and above presenting for emergency care were evaluated by the ED physician immediately on presenting to the ED for one of two medical records reviewed (MR2).

Findings include:

1) Review on May 3, 2017, of the facility's "Plan for Patient Care Emergency Department 2017," revealed "I. Scope of Service In keeping with the Mission, Vision and Values of Lehigh Valley Hospital - Schuylkill E. Norwegian, the Level II Emergency Department (ED) offers emergency health services twenty-four hours a day to patients of all ages, regardless of their ability to pay. ... III. Plan of care The Emergency Department fulfills the following responsibilities: ... documents reassessment of the patient during ED stay at least every 2 hours and prior to discharge from ED. ..."

Review on May 2, 2017, of MR1 revealed this patient presented to the ED on April 1, 2017, with the complaint of a dislocated left elbow. Nursing documentation revealed this patient was evaluated by the nurse at 2015. The next documentation of a nursing evaluation on MR1 was at 2255. There was no documentation MR1 was seen by a nurse between 2015 and 2255.

Interview with EMP1 at approximately 1:00 PM on May 3, 2017, confirmed there was no documentation MR1 was seen by a nurse between 2015 and 2255.

2) Review on May 3, 2017, of the facility's policy "Pediatric Patients presenting to the ED," revised December 30, 2016, revealed "Policy Statement: Pediatric patients, defined as children [less than or equal to] 16 years of age, presenting to the ED will receive appropriate emergency treatment and, if necessary, transfer to Schuylkill Medical Center - South Jackson Street Pediatric Department for inpatient care. Procedure: A pediatric patient presenting to the ED at East Norwegian will receive emergency treatment by the emergency room physician. ..."

Review on May 2, 2017, of MR7 revealed this 6-year-old patient presented to the ED on April 1, 2017, with a complaint of ear pain. There was no documentation in MR7 that the patient was seen and evaluated by the ED physician.

Review on May 2, 2017, of MR8 revealed this four-year-old patient presented to the ED on April 1, 2017, with a complaint of burning on urination. There was no documentation in MR7 that the patient was seen and evaluated by the ED physician.

Interview with EMP1 at approximately 1:00 PM on May 3, 2017, confirmed there was no documentation in MR7 and MR8 that these patients were seen and evaluated by the ED physician.

3) Review on May 3, 2017, of the facility's policy "Obstetric Patients Coming Into the Emergency Department," revised December 30, 2016, revealed "Policy Guidelines: 1. All pregnant women twenty weeks and above presenting for emergency care shall be evaluated by the emergency Department Physician immediately upon presentation to the triage nurse. ..."

Review on May 2, 2017, of MR2 revealed the patient presented to the ED on April 21, 2017. The patient was 22 weeks pregnant. The chief complaint was severe vomiting and possible dehydration. There was no documentation in MR2 that the patient was seen and evaluated by the ED physician.

Interview with EMP1 on May 3, 2017, confirmed there was no documentation in MR2 that the patient was seen and evaluated by the ED physician.