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Based on interview and record review, the facility failed to ensure that medical screening examination and/or stabilizing treatment was not delayed in order to inquire about payment status and by relying on the judgement of admitting clerks to choose when to notify the emergency department nurse of a patient arrival for one of 20 sampled patients (Patient 4). This failure delayed assessment and triage (the assignment of degrees of urgency to wounds or illnesses to decide the order of treatment) and had the potential to cause avoidable complications.

Findings:

Patient 4's medical record was reviewed. Patient 4 was a 66 year old female with complaints of increasing shortness of breath, ankle swelling, and chest tightness with a recent history of non-ST elevation myocardial infarction (heart attack) who arrived in the emergency department at 5:53 pm. The Registered Nurse (RN) conducted a triage and initial assessment at 6:20 pm, 27 minutes after arrival. Patient 4 was assigned Emergency Severity Index (ESI) (a system of classification utilized to determine severity of illness and order of treatment) level 2 (emergent).

A review of the facility policy entitled, "Triage Guidelines," last approved 12/2018, indicated that patients triaged at level 1 (resuscitation/life threatening injury) or level 2 (emergent) will be brought immediately into the emergency department and that a patient triaged at level 2 is one whose condition could easily deteriorate to requiring resuscitation or a patient who presents with symptoms suggestive of a condition requiring time-sensitive treatment. This is a patient who has a potential major life, organ or limb threat.

In an interview conducted on 12/26/18 at approximately 2 pm, the Quality Assurance Coordinator (QAC) and RN V stated that the registration clerk had the patient sit down, copied insurance cards, completed the registration, and then notified the nurse that the patient was ready. The QAC and RN V stated that if the clerk felt the patient should be seen sooner, they could call the nurse.

In an interview conducted on 12/27/18 at 11:03 am, RN Z confirmed the registration process and that the clerk made the decision when to notify the emergency department RN of a patient arrival. RN Z was unaware of the requirement for triage and medical screening exam prior to the request for financial information.

Based on closed medical record review and nursing staff interview, the hospital failed to ensure pain management intervention, reassessment, and documentation for three of 20 sampled patients (Patients 13, 7, and 1) in accordance with standards of practice and hospital policy. Failure to ensure effective monitoring of pain symptoms may result in inadequate pain control during hospitalization.

Findings:

A review of the hospital policy titled "Pain Management," dated 3/2017, listed the purpose of the policy was to assess for the presence or absence of pain during the initial assessment and periodically thereafter. Additionally, the policy guided staff to reassess pain status within 60 minutes following administration of pain medication with the reassessed score documented in the electronic medical record.

The standard of practice for the basics of pain management is to comprehensively assess pain levels pre and post medication administration (Basics of Pain Management, Food and Drug Administration, 2017). In patients where self-report is not possible observation and detection of pain-related behavior is a valuable approach to identification of pain in dementia. This includes facial expressions, body movements and vocalizations, which are helpful when assessing pain in patients with cognitive limitations (Pain Management in Patients with Dementia, Achterber et.al., 2013).

1. Patient 13's record was reviewed. Patient 13 was admitted with extensive first and second degree burns of the anterior (toward the front) thigh and abdominal wall. An admission history and physical, dated 11/11/18, described the patient as confused, and disoriented with long and short term memory loss. At the time of admission, Patient 13 did not complain of pain. Admission pharmacy orders, dated 11/11/18, included the following pain medications: Morphine Sulfate Injection 4 milligrams (mg)/milliliter (a metric unit of measure) six times daily and Norco 5-325 mg as needed every 4 hours.

Review of the Medication Administration Record (MAR) for the Morphine Sulfate Injection from 11/11-11/14/18 revealed Patient 13 received a total of 15 injections. The MAR also revealed that nursing staff did not consistently monitor for pain levels pre and post medication administration. As an example, Patient 13 received an injection on 11/11/18 at 11:07 pm. There was no documented pre-medication assessment prior to administration, rather the most recent pain assessment was done on 11/11/18 at 7:45 pm, 3 hours prior to administration. Similarly, the patient received an injection on 11/13/18 at 7:19 am. A pain assessment recorded a pain level of 10 (on a scale of 0-10, 0 being no pain and 10 being the most severe) on 11/13/18 at 8 am (post medication administration). There was no further documented pain assessment until 11/13/18 at 3:19 pm, when an additional injection was given for a pain scale of 0.

Review of the MAR for Norco tablets 5-325 mg revealed similar inconsistencies. As an example, on 11/17/18 at 7:53 am, Patient 13 received a Norco dose for a pain level of 5. There was no pain assessment until 11/17/18 at 12:30 pm, greater than 4 hours after the administration of pain medication.

In an interview on 12/27/18 at 11 am, the Quality Assurance Coordinator (QAC) stated that a pain assessment should be documented pre and post pain medication administration. In a follow up interview on 12/27/18 at 2:40 pm, the QAC stated the hospital was completing a chart audit which tracked multiple elements, one of which was the documentation of pain levels. The QAC stated that nursing staff were in-serviced, however there had not been satisfactory improvement in pain monitoring/assessment despite additional training. Review of Quality Assurance data for July-September 2018 revealed an average compliance of 32% for documentation of pain following interventions.


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2. Patient 7's medical record was reviewed. Patient 7 was 67 years old and was admitted to the emergency department on 12/13/18 at 10:36 am after a fall, complaining of 8/10 (8 out of 10) pain when taking a breath and bruising to his right hip and right knee.

Patient 7's emergency department record indicated he was initially assessed on 12/13/18 at 10:40 am and stated his pain was 8/10. Follow up assessment at 11:36 am indicated Patient 7's pain remained 8/10, and follow up assessment at 1:51 pm indicated pain remained 8/10. Nursing notes did not reflect any discussion with the attending physician regarding the patient's pain or interventions aimed at relieving Patient 7's pain. No physicians orders for pain medication were recorded in the record.

Patient 7 was discharged home at 2:26 pm with diagnoses including nondisplaced fractures anterior lateral sixth and seventh ribs (right sided broken ribs in good alignment) and a prescription for opioid (narcotic) pain medications.

In an interview conducted on 12/27/18 at approximately 9:45 am, Registered Nurse (RN) V stated that the emergency room doctors didn't like to give pain medications until the workup was complete and that Patient 7 did not receive any pain medications during the emergency department visit.

3. Patient 1's medical record was reviewed. Patient 1 was 82 years old and was admitted to the emergency department on 10/1/18 at 6:47 pm with complaints of being lethargic (little to no energy) and weak.

Patient 1's emergency department record indicated that he was initially assessed on 10/1/18 at 6:47 pm and stated his pain was 10/10. Follow up assessment at 7:36 pm did not record a pain level, and follow up assessment at 8:08 pm indicated pain level 10/10.

A physicians order for ibuprofen (a non-narcotic pain medication) was created at 8:48 pm and administered at 9:18 pm.

Follow up assessment conducted at 9:39 pm did not record a pain level. Nursing notes made no further mention of Patient 1's pain nor an evaluation of the effectiveness of the medication administered.

Patient 1 was transferred to a higher level of care via ambulance at 10:30 pm.

In an interview conducted on 12/27/18 at approximately 9:55 am, RN V acknowledged there was no reassessment of Patient 1's pain or the effectiveness of the medication given.

Based on interview and record review, the facility failed to ensure the medical privileges, license, and qualifications of a practitioner were current and accurate when hospital privileges were not evident for one physician (MD3) currently performing surgical procedures in the facility. This failure had the potential for the physician to perform surgical procedures without proper qualifications, resulting in adverse patient outcomes.

Findings:

1. On 12/27/18 at 1:30 pm, during an interview and concurrent record review with the Infection Control Nurse (ICN), a review of the credentialing file for MD3 revealed no evidence of current hospital privilege credentialing.

During an interview with acting Chief Executive Officer (CEO) on 12/28/18 at 8:40 am, she confirmed the documents were not in the file. She stated, "There is no evidence of current privileges" for MD3.

A review of the facility's Medical Staff Bylaws indicated initial appointment to the medical staff shall be for a period of one (1) year and reappointments shall be for a period of up to two years. MD3's only documented medical staff privileges were dated 1/23/14.

2. During interview with the Pharmacy Nurse (PN), on 12/26/18 at 12:05 pm, she stated there was no roster listing a practitioner's specific surgical privileges available nor did she have a way of reviewing those privileges.

During an interview with the Human Resources Director (HRD), on 12/28/18 at 9 am, she confirmed there was no way for nursing staff to review current medical staff privileges.