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Based on interview and record review, the hospital failed to ensure the nursing staff completed the admission assessment for two of four sampled patients (Patients 3 and 4) as per the hospital's P&P. This failure had the potential to result in substandard care for the patient.

Findings:

Review of the hospital's P&P titled Interdisciplinary Admission, Assessment and Reassessment revised on 10/30/24, showed the following:

* The RN completes the Nursing Admission Assessment which includes Basic Admission Information Adult, Adult Patient History, and Infectious Disease Risk Screening within 8 hours of the patient's physical admission to an inpatient bed for all patients admitted to the hospital, including patients hospitalized for observation.

* The RN Nursing admission assessment documentation includes the following components:
a. Physical Exam
b. Vital Signs
c. Allergies
d. Pain Screen
e. Abuse/Neglect/Assault Screen
f. Functional Screen
g. Nutritional Screen
h. Advance Directives/Power of Attorney
i. Suicide Risk Assessment
k. Fall/Skin Risk Assessment
l. Cultural/Spiritual Screening
m. Sensory/Communication Screen
n. Discharge Planning Screen
o. Additionally developmental, stage, age appropriate, and population specific assessment are completed as indicated.

On 8/13/25 at 1134 hours, the ED was toured with the Director of ED and the Assistant ED Nurse Manager in the presence of the Director of Quality. During the tour, RN 1 was interviewed. RN 1 stated medical surgical float nurses cared for patients who were boarding in the ED after the admission order was received the level of care as the physician's order.

On 8/13/25 at 1533 hours, RN 2 was interviewed in the presence of the Director of ED and the Assistant ED Nurse Manager. RN 2 stated RN 2 was a medical/surgical telemetry nurse. RN 2 stated the nursing admission assessment was to be performed for all admitted patients and for patients on observation status and included completing the Adult Admission History form. Review of the Adult Admission History form showed the following items were to be completed:

Pain history, Family history, Allergy, Immunization, Procedure history, Anesthesia/ sedation, Transfusion reaction and consent, Nutrition, Malnutrition screening tool, Functional/fall risk assessment, Social history, Risk assessment, Psychosocial/spiritual, Advanced Directive, CSSRS (Columbia-Suicide Severity Rating Scale), Current living status, Diabetes history, Heart failure admission assessment, PHQ-2, and AUDIT-C.

1. On 8/13/25 at 1407 hours, Patient 3's medical record was reviewed with the Director of ED and the Assistant ED Nurse Manager in the presence of the Director of Quality. Patient 3's medical record showed Patient 3 arrived at the ED on 8/12/25 at 1004 hours.

Review of the physician's order dated 8/12/25 at 2248 hours, showed to admit Patient 3 to medical surgical level of care as an observation status. Further medical record review showed the Adult Admission History was not opened to document. There was no documented evidence to show that the Adult Admission History was completed.

2. On 8/13/25 at 1430 hours, Patient 4's open medical record was reviewed with the Director of ED and the Assistant ED Nurse Manager in the presence of the Director of Quality.

Review of the physician's order dated 8/12/25 at 2250 hours, showed to admit Patient 4 to telemetry level of care as an inpatient status. Further medical record review showed the Adult Admission History was not opened to document. There was no documented evidence to show that the Adult Admission History was completed.

On 8/13/25 at 1600 hours, the Director of ED and the Director of Quality verified the above findings.

Based on interview and record review, the hospital failed to ensure the nursing staff performed the pain assessment for two of four sampled patients (Patients 1 and 3) as per the hospital's P&P, creating the risk of substandard care to the patients.

Findings:

Review of the hospital's P&P titled Pain Assessment and Reassessment revised on 12/12/24, showed the following:

* Patients admitted to Emergency Department (ED) shall receive an initial screen at the emergency department visit and at the time of admission to identify the presence of pain.

* Pain reassessments post pain medication administration will be completed as often as necessary and within one hour after treatment/intervention.

* If the screen is positive, proceed with completing and documenting an in depth pain assessment to gather detailed pain information as follows:

Pain Characteristics
(a) Location- whether pain is in abdomen, leg, arm, ankle etc.
(b) Laterality- determines if pain is on right, left side or is bilateral
(c) Quality- identifies if the pain is aching, burning, cramping etc.
(d) Time Variation- describes if pain is constant or intermittent
(e) Onset- explains if pain is gradual or sudden
(f) Duration- determines how long the pain has been
(g) Alleviating factors- identifies interventions that help pain relief such as massage, repositioning, etc.
(h) Aggravating factors- describes what makes pain worse such as movement, breathing, palpating/pressure etc.
(i) Non-pharmacological Therapy - determines if cold, heat, music therapy etc. help in pain relief
(j) The patient's history of analgesic use or abuse

1. On 8/13/25 at 1310 hours, an interview and review of Patient 1's closed medical record was conducted with the Director of ED and the Assistant ED Nurse Manager in the presence of the Director of Quality.

Patient 1's medical record showed Patient 1 arrived in the ED on 4/3/25 at 1107 hours, and was discharged from the ED on 4/3/25 at 1534 hours.

Review of the Tier 2 Triage dated 4/3/25 at 1112 hours, showed Patient 1 complained of pain to the upper abdomen with the pain score of 10 out of 10 (0 being no pain and 10 being the worst pain). There was no documentation to show pain time variation, onset, aggravating and alleviating factors, non-pharmacological therapy, and the patient's history of analgesic use or abuse.

Review of the Orders-Medication dated 4/3/25 at 1327 hours, showed to administer morphine (narcotic pain medication) 4 mg IVP to Patient 1. Review of the MAR dated 4/3/25 at 1335 hours, showed Patient 1 received morphine.

Review of the Pain documentation showed Patient 1 complained of pain. The pain score was nine out of 10 on 4/3/25 at 1405 hours, and two out of 10 on 4/3/25 at 1527 hours.

During an interview with the Director of ED and the Assistant ED Nurse Manager in the presence of the Director of Quality, the Director of ED and the Assistant ED Nurse Manager stated the pain level documented on 4/3/25 1405 hours, must have been a pain level performed on 4/3/25 at 1335 hours. The Director of ED and Assistant ED Nurse Manager verified there was no reassessment within one hour after the medication was given on 4/3/25 at 1335 hours.

2. On 8/13/25 at 1407 hours, an interview and concurrent review of Patient 3's medical record was conducted with the Director of ED and the Assistant ED Nurse Manager in the presence of the Director of Quality.

Review of the Pain Assessment dated 8/12/25 at 1007 hours, showed Patient 3 complained of abdominal pain. The pain score was nine out of 10.

There was no documentation to show pain onset, aggravating and alleviating factors, non-pharmacological therapy, and the patient's history of analgesic use or abuse.

Review of the Pain Assessment dated 8/12/25 at 1229 hours, showed Patient 3 reported pain, but there was no documented pain level.

On 8/3/25 at 1600 hours, the Director of ED and the Director of Quality verified the above findings.