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Based on documentation in 4 of 6 medical records reviewed of patients (Patient records 2, 4, 5, and 6) who presented to the ED with a lower extremity skin and/or wound related condition, and policy and procedure review, it was determined the hospital failed to ensure that the registered nurse evaluated all of the patient's nursing care needs. There was a lack of initial and on-going assessments related to patient pain and pain medications as required by hospital policies and procedures.

Findings included:

1. The following policies and procedures were reviewed:

The "Emergency Department Acute Pain Protocol (Adult Patient)," revision "050410" reflected "...Nursing staff to reassess pain every 20 minutes minimum and more frequently prn while using protocol. Notify physician and obtain order if more frequent or additional pain medication is needed." The protocol included a table for determining the hydromorphone (Dilaudid) dosage to be administered based on the patient's pain score, age and weight. The protocol also included specific interventions to be implemented (such as "Apply 02 3[liters per minute by nasal canula] and notify MD...") if the patient developed a respiratory rate of less than 10 respirations per minute, an oxygen saturation less than 92%, or a decrease in level of consciousness (symptoms of over sedation/respiratory depression) after administration of the IV Dilaudid.

The "Emergency Department Documentation Guidelines," Document #: OR.274.33, effective 12/16/2013 reflected "Purpose: To provide standards for documentation on patients in the Emergency Department..." The policy and procedure required documentation of a full set of vitals signs and a pain scale on all patients. Additional requirements included vital signs and a 0-10 pain score every 2 hours, or more frequently based on patient condition.

The "Pediatric Pain Scale" updated 01/2012 reflected that a FLACC scale [a scale used to score pain] was to be used to assist in evaluating pain in children ages 12 months to 3 years."

2. The 03/06/2013 medical record for Patient 5 was reviewed. The "ED Clinical Service Record" dated 03/06/2013 reflected the triage time was 1048, the patient's chief complaint was right ankle cellulitis, and his/her pain was rated a score of "10" on a 0-10 pain scale. The section on the service record designed to document the patient's weight was blank. Documentation on the form reflected that an "ED Pain Protocol" was ordered. The patient was discharged on 03/06/2013 at 1459 with a diagnosis of cellulitis.

The "Emergency Department Flow Sheet" dated 03/06/2013 reflected the patient was administered "dilaudid 0.5" IV at 1335 and another dose of "dilaudid 0.5" IV at 1353. The patient's pain score was documented as "7" at 1353, and "5" at 1459 (more than an hour after the patient was given the second dose of Dilaudid at 1353).

The record lacked documentation that the nurse assessed the patient's pain timely before administering the 1335 dose of Dilaudid or obtained a weight in order to ensure an appropriate dosage of the medication was administered.

The record lacked documentation that the nurse checked the patient's respiratory rate and oxygen saturation timely after administering the 1353 dose of Dilaudid in order to evaluate the patient for symptoms of over sedation. The record reflected a respiratory rate and an oxygen saturation were documented at 1353. However, the next respiratory rate and oxygen saturation were not documented until 1459 (more than an hour after the patient was given the 1353 dose of Dilaudid). These findings were reviewed and verified during an interview with I4 on 12/17/2013 at 1215.

The record further lacked documentation that the nurse reassessed the patient's pain every 20 minutes in accordance with the hospital's "Emergency Department Acute Pain Protocol (Adult Patient)."

3. The 02/28/2013 record for Patient 4 was reviewed. The "ED Clinical Service Record" dated 02/28/2013 reflected the triage time was 2205 and the patient's chief complaint was left lower extremity skin infection. The "Emergency Department Flow Sheet" dated 02/28/2013 reflected the patient was administered Tylenol 1 gram by mouth at 2310. The patient was discharged on 03/01/2013 at 0015 with a diagnosis of cellulitis. The record lacked documentation that a pain score and/or scale had been completed as required by hospital policy. These findings were reviewed and verified during an interview with I4 on 12/17/2013 at 1215.

4. The 03/22/2013 record for a pediatric patient, Patient 2 was reviewed. The "ED Clinical Service Record" reflected the triage time was 1210, and the patient was 2 years old with a chief complaint of "wound/[fracture] recheck." The "Triage Vital Signs" section of the service record reflected that the patient was crying. The patient was discharged on 03/22/2013 at 1315. The record lacked documentation that a FLACC scale had been used, or that a pain score scale had been completed by the registered nurse as required by hospital policy. These findings were reviewed during an interview with I4 on 12/17/2013 at 1230.

5. Similar findings were identified during a review of the record for Patient 6.

Based on documentation in 4 of 6 medical records reviewed of patients (Patient records 2, 4, 5, and 6) who presented to the ED with a lower extremity skin and/or wound related condition, and policy and procedure review, it was determined the hospital failed to ensure that the registered nurse evaluated all of the patient's nursing care needs. There was a lack of initial and on-going assessments related to patient pain and pain medications as required by hospital policies and procedures.

Findings included:

1. The following policies and procedures were reviewed:

The "Emergency Department Acute Pain Protocol (Adult Patient)," revision "050410" reflected "...Nursing staff to reassess pain every 20 minutes minimum and more frequently prn while using protocol. Notify physician and obtain order if more frequent or additional pain medication is needed." The protocol included a table for determining the hydromorphone (Dilaudid) dosage to be administered based on the patient's pain score, age and weight. The protocol also included specific interventions to be implemented (such as "Apply 02 3[liters per minute by nasal canula] and notify MD...") if the patient developed a respiratory rate of less than 10 respirations per minute, an oxygen saturation less than 92%, or a decrease in level of consciousness (symptoms of over sedation/respiratory depression) after administration of the IV Dilaudid.

The "Emergency Department Documentation Guidelines," Document #: OR.274.33, effective 12/16/2013 reflected "Purpose: To provide standards for documentation on patients in the Emergency Department..." The policy and procedure required documentation of a full set of vitals signs and a pain scale on all patients. Additional requirements included vital signs and a 0-10 pain score every 2 hours, or more frequently based on patient condition.

The "Pediatric Pain Scale" updated 01/2012 reflected that a FLACC scale [a scale used to score pain] was to be used to assist in evaluating pain in children ages 12 months to 3 years."

2. The 03/06/2013 medical record for Patient 5 was reviewed. The "ED Clinical Service Record" dated 03/06/2013 reflected the triage time was 1048, the patient's chief complaint was right ankle cellulitis, and his/her pain was rated a score of "10" on a 0-10 pain scale. The section on the service record designed to document the patient's weight was blank. Documentation on the form reflected that an "ED Pain Protocol" was ordered. The patient was discharged on 03/06/2013 at 1459 with a diagnosis of cellulitis.

The "Emergency Department Flow Sheet" dated 03/06/2013 reflected the patient was administered "dilaudid 0.5" IV at 1335 and another dose of "dilaudid 0.5" IV at 1353. The patient's pain score was documented as "7" at 1353, and "5" at 1459 (more than an hour after the patient was given the second dose of Dilaudid at 1353).

The record lacked documentation that the nurse assessed the patient's pain timely before administering the 1335 dose of Dilaudid or obtained a weight in order to ensure an appropriate dosage of the medication was administered.

The record lacked documentation that the nurse checked the patient's respiratory rate and oxygen saturation timely after administering the 1353 dose of Dilaudid in order to evaluate the patient for symptoms of over sedation. The record reflected a respiratory rate and an oxygen saturation were documented at 1353. However, the next respiratory rate and oxygen saturation were not documented until 1459 (more than an hour after the patient was given the 1353 dose of Dilaudid). These findings were reviewed and verified during an interview with I4 on 12/17/2013 at 1215.

The record further lacked documentation that the nurse reassessed the patient's pain every 20 minutes in accordance with the hospital's "Emergency Department Acute Pain Protocol (Adult Patient)."

3. The 02/28/2013 record for Patient 4 was reviewed. The "ED Clinical Service Record" dated 02/28/2013 reflected the triage time was 2205 and the patient's chief complaint was left lower extremity skin infection. The "Emergency Department Flow Sheet" dated 02/28/2013 reflected the patient was administered Tylenol 1 gram by mouth at 2310. The patient was discharged on 03/01/2013 at 0015 with a diagnosis of cellulitis. The record lacked documentation that a pain score and/or scale had been completed as required by hospital policy. These findings were reviewed and verified during an interview with I4 on 12/17/2013 at 1215.

4. The 03/22/2013 record for a pediatric patient, Patient 2 was reviewed. The "ED Clinical Service Record" reflected the triage time was 1210, and the patient was 2 years old with a chief complaint of "wound/[fracture] recheck." The "Triage Vital Signs" section of the service record reflected that the patient was crying. The patient was discharged on 03/22/2013 at 1315. The record lacked documentation that a FLACC scale had been used, or that a pain score scale had been completed by the registered nurse as required by hospital policy. These findings were reviewed during an interview with I4 on 12/17/2013 at 1230.

5. Similar findings were identified during a review of the record for Patient 6.