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Based on record review, policy review and staff interview it was determined the facility failed to ensure the Emergency Department nursing staff assessed and reassessed patients according to facility policies and generally accepted standards of care for 4 (#1, #2, #7, and #9) of 10 sampled patients, and

These practices fail to ensure patients receive safe, effective, quality care in the Emergency Department of the facility.

Findings include:

1. Patient #1 arrived at the Emergency Department (ED) via private vehicle on 6/23/2012 at 6:09 a.m. complaining of chest pain. The Triage Record dated 6/23/2012 at 6:09 a.m. indicated the patient reported his pain was 8 on a scale of 0-10 indicating severe pain. His vital signs were: pulse 62, respirations 26, oxygen saturation 97%, and blood pressure 141/81. At 6:11 a.m. on 6/23/2012 his pain level was documented as 10 on a scale of 0-10, indicating the worst possible pain. An EKG performed on 6/23/2012 at 6:16 a.m. showed abnormalities consistent with Myocardial Infarction (heart attack). A review of the Medication Administration Record failed to reveal documentation the patient was given medication to relieve his pain between the time of his arrival at 6:09 a.m. and 6:45 a.m. when the patient went into a lethal cardiac rhythm requiring resuscitation.

2. Patient #2 arrived at the ED on 7/2/2012 at 2:29 p.m. via private vehicle complaining of chest pain with nausea and vomiting. The Triage Note dated 7/2/2012 at 2:30 p.m. documented the patient described his pain as 10 on a scale of 0-10, indicating it was the most severe pain he had experienced. His vital signs on arrival were pulse 60, respirations 18, oxygen saturation 97%, and blood pressure 144/76.

A review of the record failed to reveal any nursing reassessment of the patient between the time he was seen by the triage nurse at 2:30 p.m. and the time he was examined by the ED physician at 4:47 p.m. on 7/2/2012.

The Medication Administration Record revealed the first treatment the patient received for his chest pain was intravenous Nitroglycerin initiated at 5:15 p.m., approximately 2 hours and 45 minutes after the triage nurse documented a pain level of 10/10. He was also given sublingual (under the tongue) Nitroglycerine 0.4 mg tablets at 5:35 p.m., 5:40 p.m. and 5:48 p.m.

3. Patient #6 arrived at the ED on 7/2/2012 at 11:16 a.m. via ambulance complaining of chest pain. The Triage Nursing Note dated 7/2/2012 at 11:42 a.m. and signed by the ED Staff RN indicated the patient's vital signs were pulse 52, respirations 19, oxygen saturation 99% and blood pressure 117/56. The patient reported his pain at 5 on a scale of 0-10 at that time. Review of the Nurses Notes documented the patient reported his pain was 8 at 11:33 a.m. on 7/2/2102. The ED Record indicated the patient was examined by the ED physician on 7/2/2012 at 12:37 p.m. The physician assessment indicated the patient was in moderate distress and described the degree of pain at the time of examination as moderate. The Medication Administration record indicated the physician ordered Morphine 2 mg IV at 1:00 p.m. and the medication was administered by the ED RN at 1:42 p.m. Review of the record failed to reveal documentation of nursing assessment of the patient's pain between 11:33 a.m. on 7/2/2012 in the ED and 7:30 a.m. on 7/3/2012 by the staff RN on the Cardiac Step-Down nursing unit.

4. Patient #9 arrived at the ED on 10/16/2012 at 10:16 a.m. via private vehicle complaining of chest pain. The Triage notes dated 10/16/2012 at 10:16 a.m. documented his vital signs were pulse 78, respirations 18, oxygen saturation 99% and blood pressure 151/107 (abnormally high but not critical). His pain was documented as 3 on a scale of 0-10 at 10:39 a.m.The Clinical Assessments record failed to reveal documentation of a nursing assessment of the patient ' s pain level between 10/16/2012 at 10:39 a.m.

5. An interview, policy review and record review were conducted with the Risk Manager on 10/18/2012 at approximately 5:00 p.m. She confirmed the findings regarding assessment and reassessment, as documented above, were not in compliance with facility policy.