The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.
|ST FRANCIS HOSPITAL||241 NORTH ROAD POUGHKEEPSIE, NY||March 17, 2014|
|VIOLATION: ORGANIZATION AND DIRECTION||Tag No: A1101|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record reviews, policy reviews and staff interviews, it was determined that the facility failed to ensure that the patient was provided with emergency care as needed. This was found in 1 of 14 medical records reviewed. [Medical Record (MR) #1]
MR#1 was reviewed on March 13, 2014. This [AGE] year old presented to the emergency room (ER) on August 16, 2013 with complaints of difficulty speaking, a left sided weakness, a left facial droop and a headache. The patient's previous medical history included a Transient Ischemic Attack, Hypertension and Migraine headaches with focal neurological symptoms. The patient reported that he had similar episodes in the past and the spasms in the last episode which lasted for 3 days.
A code stroke was called upon arrival and the patient was transported to the Radiology Department for a CT-Scan of the head to rule out a stroke.
An initial nursing assessment revealed that the patient had numbness of the legs and feet, slurred speech and muscle contractions. The record did not indicate the location of the muscle contractions. The patient's Modified Rank Scale score was 4 on a scale of 0-no symptoms to 6-dead. This score of 4 means the patient had "moderately severe disability; unable to walk without assistance."
The Neurologist documented at 8:30 PM that the patient had "some headache" and that "coordination was not possible." The patient remained in the ER until 11:30 AM the next day. He was discharged from the ER and sent to the triage waiting area to await his ride home.
Staff #1 an RN, was interviewed on March 17, 2014 at 11:50 AM. She stated that she was in charge of the ED that night and that it was "hard to remember." She stated she took responsibility of the patient when he was medically cleared and transferred him to the psychiatric area. She stated the patient had a lot of anxiety. She reported that she didn't' know if the patient had slurred speech. She also stated "the patient was assisted " to the psychiatric area.
There was no documented evidence in the medical record that any member of the staff assessed the pain score for the patient's headache upon arrival. In addition, there was no evidence that this patient's level of pain was reassessed throughout his ER stay as per facility's Pain Assessment policy.
Also, there was no evidence that the patient received pain medication for his discomfort. This discomfort was as noted in the record, upon the patient's arrival to the facility. Furthermore, there was no documented evidence in the medical record, that a nurse reassessed the patient's slurred speech, muscle contractions or facial droop during his ER stay.
There was no documentation that the Nursing Staff reassessed the patient's symptoms during the course of the emergency room (ER) visit on August 16, 2913.
The facility's operational policy titled "Pain Assessment and Management" which was last reviewed/revised on 11/29/12 stated "a pain scale will be utilized to help the patient communicate pain and guide treatment. Patients will be assessed for pain on presentation/admission, and at routine intervals as defined by nursing policy, and pain will be control/managed by the utilization of pharmacological interventions (including Complementary Therapies)." The policy further stated "patients will be reassessed periodically for pain and relief from pain and responses to treatment with modifications to the pain management plan as needed. Documentation of the patient pain will include the intensity of the pain and all interventions." There was no documented evidence in the medical record to indicate that this policy was followed by the ER staff.