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Based on record review and interview, staff failed to address patient's advanced directives in an outpatient setting (emergency department) in 9 of 10 out of a total of 11 medical records reviewed (Patient #1, 2, 3, 5, 6, 7, 8, 9, and 10).

Findings include:

In an email received on 7/22/2020 at 11:30 AM from Quality Director A regarding a policy for advance directives, Director A responded, "ED (emergency department) follows the outpatient algorithm. In Epic (electronic health record) there is a question that is asked during the Triage as to if they have one. Then the nurses follow the algorithm."

The facility policy titled, "Advance Directives," #10.13 dated 12/2004, revealed in part, "PROCEDURE II. OUTPATIENT AMBULATORY SETTING: Follow Advance Directive Process on Attachment B...Attachment B; Outpatient Advance Directive Process; Start>Do you have an Advance Directive?" A pathway is available if the patient answers yes, and a separate pathway is available if the patient answers no.

A review of the electronic health record triage assessment questions revealed the first two advance directive questions to be as follows: Have you reviewed your Advance Directive and is it valid for this stay?" and "Advance Directive:"

Medical record reviews for Patients #1, 2, 3, 5, 6, 7, 8, 9, and 10 revealed NA (not applicable) as the entry by nursing to the first two advance directive questions for Patient #1, 2, 5, 6, 7, 8, 9, and 10. Patient #3 had a "no" answer for the first question but NA for the second question.

An interview with Registered Nurse F was conducted on 7/23/2020 at 3:19 PM. In response to whether or not there was ever a reason to answer NA in the advance directive questions, Nurse F responded, "I don't know how to answer that question without looking at a computer. It's a yes or no question."

Based on record review and interview, nursing staff failed to ensure that patient's presenting complaints bringing them to the emergency department were assessed and/or failed to ensure that pain management was reassessed according to the facility's expectations in 4 out of 10 out of a total of 11 medical records reviewed (Patients #1, 6, 8, and 11).

Findings include:

A policy for patient assessment was requested and Quality Director A responded that the facility does not have a patient assessment policy but follows the assessment guidelines from Elsevier. The guidelines within the document, "Assessment: General Survey" revealed in part, "If the patient is in acute distress, immediately assess the affected body system(s). Assessment findings may change the direction of the examination...Assess the patient for acute distress..."

The Elsevier document titled, "Pain Assessment and Management," revealed in part, "Reassess the patient's pain status, allowing for sufficient onset of action per medication, route, and the patient's condition."

In an interview with Emergency Department Registered Nurse F on 7/22/2020 at 3:19 PM regarding assessment and documentation of patients presenting complaints, Nurse F stated, "Minimally I assess and document on the presenting complaint."

In an interview with Emergency Department Director C on 7/23/2020 at 12:00 PM regarding nursing assessments of body systems and pain reassessments, Director C stated that there was a neuro (neurological) status comment that includes cardio/respiratory and then it gets more involved for things like flank pain and abdominal pain. Director C stated there should be a, "Focused assessment on the chief complaint." Director C stated that a pain assessment is expected for every patient, "it's one of our vital signs." Regarding pain reassessment after medications or interventions, Director C stated, "I would expect a reassessment prior to discharge." Regarding reassessment after intravenous (IV) pain medication, Director C stated, "There is not a time frame but a reasonable expectation would be 30 minutes to an hour."

A review of Patient #1's emergency department (ED) nursing documentation revealed that Patient #1 presented to the ED on 6/22/2020 at 4:05 AM with complaints of abdominal pain. Patient #1 received IV Fentanyl (narcotic pain reliever) at 4:45 AM and IV Toradol (non-steroidal anti-inflammatory) at 6:45 AM. Patient #1 was discharged at 8:21 AM on 6/22/2020. Nursing documentation revealed pain as a 10 (0-10 scale with 10 being severe) in triage and no pain on discharge, but no pain reassessments in between. There was no focused abdominal pain assessment documented by nursing. In an interview with Director C on 7/23/2020 at 12:21 PM regarding these findings, Director C stated, "Ya, I don't find that (abdominal assessment)," and regarding pain reassessments, "I can't find assessments after the medications. There is a note that (Patient #1) is at rest about 40 minutes after medication but they don't have a note about the pain score. I would hope there would be a pain score."

A review of Patient #6's ED nursing documentation revealed that Patient #6 presented to the ED on 6/3/2020 at 10:47 PM with complaints of abdominal pain and blood in the urine. Patient #6 was discharged at 1:40 AM on 6/4/2020. No pain medications were given. Patient #6 reported a pain level of 6 on arrival to the ED and there were no further pain assessments documented prior to departure where Patient #6 "refused discharge vital signs." In an interview with Director C on 7/23/2020 at 12:30 PM regarding these findings, Director C stated, "There is a goal that says acceptable pain level achieved and the response is "met" and documentation that the patient was feeling better but they didn't get an actual pain score. My expectation is to get a pain score."

A review of Patient #8's ED nursing documentation revealed that Patient #8 presented to the ED on 6/21/2020 at 10:34 PM with complaints of abdominal pain and chest tightness. Patient #8 was discharged at 5:23 AM on 6/22/2020. Patient #8 reported a pain level of 7 at 10:44 PM in triage. Patient #8 received a GI (gastrointestinal) cocktail and tylenol at 1:42 AM. The following entries were documented regarding pain reassessments:
11:15 PM: pain level 10
2:30 AM-vital signs documented, pain level=no result
3:00 AM-vital signs documented, pain level=no result
4:00 AM-vital signs documented, pain level=no result
5:00 AM-vital signs documented, pain level=no result
In an interview with Director C on 7/23/2020 at 12:38 PM regarding these findings, Director C stated that the vital signs were from the vital sign monitor but that staff were not documenting the pain score.

A review of Patient #11's nursing documentation revealed that Patient #11 presented to the ED on 6/23/2020 at 7:03 PM with complaints of difficulty breathing and right lower quadrant abdominal pain. Patient #11 was discharged at 10:36 PM. There was no focused assessment documented regarding the abdominal pain. In an interview with Director C on 7/23/2020 at 12:47 PM regarding these findings, Director C stated, "No, there was an update at 8:00 PM stating the patient was resting comfortably and denies pain, but I don't see an abdominal pain assessment."