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Based on observation, interview and record review, the facility failed to protect ad promote each patient's rights when:

1. Staff in the Emergency Department (ED) did not ensure Patient (Pt) 8 was provided care in a safe setting. Nursing staff and emergency technician did not follow hospital policies and procedures meant to keep Pt 8 safe. As a result, Pt 8 fell on 11/25/21 and struck his head and suffered an intracerebral bleed, was transported to a higher level of care and died on 12/2/21. (refer to A144)

2. Staff did not follow policies and procedures for grievances for Patient 1 when Pt 1's grievance was not resolved in accordance with the grievance procedure. (refer to A118)

The cumulative effect of these systemic problems resulted in the facility's inability to ensure the provision of quality health care in a safe setting and in accordance with the Condition of Particpation for Patient Rights.

Based on interview and record review, the facility failed to ensure one of one sample patients' (Patient 1) grievance (a written or verbal complaint) was resolved in a timely manner when the facility did not respond to Patient (Pt) 1 in writing of the resolution to Pt 1's grievance in accordance with the facility's policy titled, "Patient Grievance Policy".

This failure resulted in Pt 1's grievance to be unresolved and placed other patients at risk for their grievances to be unresolved, violating their rights.

Findings:

During a review of Patient (Pt) 1's "History and Physical" (H&P), dated 9/17/21, the H&P indicated, " ... CHIEF COMPLAINT: Hematuria (the presence of blood in a person's urine) blocked catheter (tube that is inserted into the bladder) ...HISTORY OF PRESENT ILLNESS ...85 years old male came to the emergency room complaining of blocked Foley catheter (flexible tube placed in the bladder to drain urine ) ... Patient had TURP (transurethral resection of the prostate- surgery to remove parts of the prostate gland [walnut-sized gland located between the bladder and the penis] through the penis) done by patient urologist (physician diagnoses and treats diseases of the urinary tract system) and patient has indwelling (placed or implanted within the body) Foley catheter ... Foley catheter was not draining and draining blood clots so he comes to the emergency room ... Patient being hospitalized for further evaluation continuous bladder irrigation (procedure to open a plugged catheter) and follow-up urology consultation ... Vital Signs (measurements taken to help assess the general physical health of a person, give clues to possible diseases, and show progress toward recovery): Temperature: 37.1 (09/16 23:48 [11:48 p.m.]) ... Pulse: 110 (pulse for healthy adults ranges from 60 to 100 beats per minute) (09/16 23:48 [11:48 p.m.]) ... Respiration: 18 (09/16 23:48 [11:48 p.m.) ... BP (blood pressure- amount of blood your heart pumps and the amount of resistance to blood flow in your arteries) : 184/90 (normal blood pressure for most adults is defined as a systolic pressure of less than 120 and a diastolic pressure [top number] of less than 80 [bottom number]) (09/16 23:48 [11:48 p.m.]) ... Pulse Ox (oximetry- measuring of the percentage of oxygen-saturated hemoglobin in the blood): 98 (09/16 23:48 [11:48 p.m.]) ... Pain Score: 10 (pain scale is a numerical scale from zero to ten. Zero means no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) (09/16 23:50 [11:50 p.m.]) ... "

During a concurrent interview and record review at 11/24/21, at 1:35 p.m., with the Emergency Department Manager (EDM), Pt 1's electronic clinical records dated 9/16/21 through 9/17/21 were reviewed. The EDM stated she was familiar with Pt 1's ED encounter and validated Pt 1's physician's orders indicated:

" ...HYDROmorphone (medication used to treat moderate to severe pain) ([brand name] Inj [injection]) (HYDROmorphone 0.5 mg (milligrams- units of measurement) / (per) 0.5 ml (milliliter- units of measurement) INJ 0.5 ml ([brand name] GEq [generic equivalent]) 0.5mg, IV (intravenous- into the skin) Push, Inject, Q3h (every 3 hours), Routine, PRN (as needed), Pain- Moderate...09/17/21 0:38:00 PDT (pacific daylight time) ...

HYDROmorphone ([brand name] Inj) (HYDROmorphone 0.5 mg/0.5 ml INJ 0.5 ml ([brand name] GEq) 0.5 mg, IV Push, Inject, Q3h, Routine, PRN, Pain· Moderate, 09/17/21 5:44:00 PDT ...

HYDROmorphone ([brand name] Inj) (HYDROmorphone 1 mg/ml INJ 1 ml ([brand name] GEq) 1 mg, IV Push, Inject, Q3h, Routine, PRN, Pain· Severe, 09/17/21 5:44:00 PDT ..."

The EDM validated between 9/16/21 at 11:51 p.m. through 9/17/21 at 8:31 a.m., Pt 1's pain medications were not administered as ordered by the physician. The EDM stated pain medications should have been administered as ordered to manage or address the pain of patients or to minimize the pain patients were experiencing to provide a level of comfort.

During a concurrent interview and record review at 11/29/21 at 11:25 a.m., with Registered Nurse (RN) 4, Pt 1's electronic clinical records were reviewed. RN 4 stated he cared for Pt 1 and validated on admission (9/17/21), Pt 1's pain score was 10/10 (severe pain). RN 4 reviewed Pt 1's electronic clinical records and validated Pt 1's physician orders indicated:

" ... HYDROmorphone ([brand name] Inj) (HYDROmorphone 0.5 mg/0.5 ml INJ 0.5 ml ([brand name] GEq) 0.5mg, IV Push, Inject, Q3h, Routine, PRN, Pain- Moderate ...09/17/21 0:38:00 PDT ...

HYDROmorphone ([brand name] Inj) (HYDROmorphone 0.5 mg/0.5 ml INJ 0.5 ml ([brand name] GEq) 0.5 mg, IV Push, Inject, Q3h, Routine, PRN, Pain· Moderate, 09/17/21 5:44:00 PDT ...

HYDROmorphone ([brand name] Inj) (HYDROmorphone 1 mg/ml INJ 1 ml ([brand name] GEq) 1 mg, IV Push, Inject, Q3h, Routine, PRN, Pain· Severe, 09/17/21 5:44:00 PDT ..."

RN 4 validated Pt 1's pain medications were not administered to Pt 1 from admission to when Pt 1 left the hospital (9/16/21 at 11:50 p.m. to 9/17/21 at 8:31 a.m., a total of eight hours and 41 minutes). RN 4 stated RNs should administer pain medication as ordered to relieve patients' pain or to manage patients' pain to keep patient comfortable.

During an interview on 11/22/21, at 8:38 a.m., with Pt 1, Pt 1 stated he went to [name of hospital] on 9/16/21 and was seen in ED. Pt 1 stated he waited several hours, no one helped him address the awful pain he experienced. Pt 1 stated he screamed in pain, but ED staff did not give him any pain medication while he was in the ED. Pt 1 stated he during his entire stay while in the ED, did not receive any pain medication.

During a concurrent interview and record review on 12/2/21, at 9:47 a.m., with the Director of Quality, Risk, Accreditation (DQRA), the facility's "Grievance Log" dated, 9/1/21 through 10/24/21 was reviewed. The DQRA validated the Grievance Log indicated, " ...Date RM [Risk Management] Notified 10/1/2021 (via telephone by OR [Operating room] Director... Patient Name [Pt 1]... Date(s) of Service 9/16/21- 9/17/21... Unit(s) ED (Emergency Department)... Complaint Summary Upset re: pain management..." The DQRA stated Pt 1's surgeon called the Director of Surgical Services (DSS) and informed the DSS of Pt 1's ED encounter where Pt 1 was in pain and pain analgesia (relief of pain) was not administered to Pt 1. The DQRA stated she was informed of the information from DSS and Pt 1's grievance was relayed to the Risk Management Department. The DQRA stated the facility did not respond to Pt 1 in writing regarding Pt 1's grievance. The DQRA stated the facility should have notified Pt 1 or the patient's representative in writing and every attempt would be made to resolve the grievance as promptly as possible. The DQRA state the hospital would notify the patient or the patient's representative if there would be a delay beyond the seven days to provide a written response in order to continuously improve quality of and to resolve any grievance timely.

During a review of the facility's policy and procedure (P&P) titled, "Patient Grievance Policy," dated January 2020, the P&P indicated, " ...PURPOSE: To provide guidelines for the investigation and prompt resolution of patient and/or family complaints and grievances and to support our efforts to continuously improve quality of care at [name of facility], and to treat patients and visitors with courtesy and respect...The hospital is committed to the timely resolution of any concern, complaint or grievance raised by the patient, patient's representative or their family... Definitions... Grievance: a written or verbal complaint (when the verbal complaint is not resolved at the time of the complaint by staff present) by a patient, or the patient's representative, regarding the patient's care, abuse or neglect, issues related to the hospital's compliance with the Centers for Medicare and Medicaid Services (CMS) Hospital Conditions of Participation (CoP), or a Medicare beneficiary billing complaint related to rights and limitations provided by 42 CFR §489... A verbal complaint is a grievance if it cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff for later resolution, requires investigation, and/or requires further actions for resolution... Complaints unable to be resolved by the staff present and to the satisfaction of the complainant will become a grievance and will be documented by completing an occurrence report. Depending on the nature of the grievance, Patient Relations and/or Risk Management will follow-up and after collaboration with the department leader, will respond back in writing to the patient or the patient's representative... All grievances will be responded to in writing and every attempt will be made to resolve the grievance as promptly as possible...The hospital will notify the patient or the patient's representative if there will be a delay beyond 7 days to provide a written response... The written response will be provided by the Risk Management or Patient Experience departments... The written response must contain: The name of the hospital contact person (Risk Manager or Patient Relations)... The steps taken on behalf of the patient to investigate the grievance... The results of the grievance process... The date of completion... "

Based on interview and record review, the hospital failed to ensure patients received care in a safe setting for one of three patients (Patient [Pt] 8) when nursing staff and emergency care technician (ECT) staff assigned to care for Pt 8 did not follow policies and procedures designed to keep patients safe. Nurses did not follow the "Fall Precaution" policy and procedure to assess the risk for falls for Pt 8 and did not develop and implement a care plan with effective interventions to address Pt 8's needs. Nurses did not follow the "Alcohol Withdrawal: Care of Patient" policy and procedures for Pt 8 and nurses did not address Pt 8's neurological decline in a timely manner after he fell and struck the back of his head on 11/25/21. After Pt 8's fall, ECT 2 did not follow the "Behavioral Health" policy and procedure for 1:1 Patient Safety Attendant (PSA) care for Pt 8.

These failures contributed to Pt 8's fall where he struck the back of his head; a delay in recognizing the level of injury and change of condition. Pt 8 suffered an intracerebral bleed requiring transport to intensive care and neurosurgical care at a local trauma hospital and died on 12/2/21 at 5:14 p.m.

Findings:

Pt 8's clinical records were reviewed and indicated Pt 8 was a 44-year-old male brought in by ambulance to the Emergency Department (ED) on 11/24/21, at 7:21 p.m. for altered mental status (AMS - generalized term used to describe mental functioning and may range from mild confusion to severe such as coma). Pt 8 was homeless with a history of bipolar disorder (a mental condition marked by alternating periods of elation and depression) and alcohol abuse (a chronic disease characterized by uncontrolled drinking and occupation with alcohol). Pt 8 was diagnosed with alcohol withdrawal (symptoms that occur when someone stops using alcohol after a period of heavy drinking), Hallucination (an experience involving the apparent perception of something not present), Paranoia (an unrealistic distrust of other), and Suicidal Ideation (thinking about or planning to end one's on life). Pt 8 was placed on a Health and Safety code 1799 hold (a law that provides a physician to detain a person in the ED for 24 hours for medical treatment with psychiatric problems that require attention) as Pt 8 presented a danger to himself. Pt 8 was admitted to the Behavioral unit (an area of the hospital designed to care for patients with mental health symptoms) of the ED on 11/24/21, at 11:09 p.m. On 11/25/21, at 2:20 p.m. Pt 8 had a witnessed fall by Security Guard (SG) 2. RN 20 assessed Pt 8 immediately after the fall and documented Pt 8 had no physical or neurological deficit (abnormal function of a body area) and was ordered to notify the MD (Medical Doctor) of change in condition. The clinical record indicated that on 11/25/21, at 11:39 p.m. (approximately 9 hours after the fall), "Pt 8 was unresponsive, decorticate posturing (an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held straight out), incontinent of urine (unable to control bladder function), and pupils dilated (larger than usual) and uneven," according to the nurses notes documented by RN 37. A CT scan (a computerized tomography scan that combines a series of X-ray images taken from different angles of the body) of Pt 8's head on 11/26/21, at 12:47 a.m. indicated a large left sided subdural hematoma (a pool of blood between the brain and its outermost covering) measuring 25 millimeters (mm - approximately one inch) in thickness. There was a left to right midline shift of 16 mm (approximately three-quarters of an inch) with partial effacement (thinning) of the left lateral ventricle (fluid filled cavity inside the brain). Pt 8 was intubated (a tube inserted into the windpipe) for airway protection on 11/25/21, at 11:51 p.m. and was transferred to Hospital B intensive care unit for higher level of care on 11/25/21, at 2:01 a.m. where Pt 8 died on 12/2/21, at 5:14 a.m.

During a concurrent interview and record review, on 12/6/21, at 3:18 p.m., with RN 18, RN 18 stated she was assigned to care for Pt 8 on admission. RN 18 stated the admission assessment of Pt 8, dated 11/24/21 indicated Pt 8 was admitted to the Behavioral unit on 11/24/21 at 11:23 p.m. RN 18 stated she documented that Pt 8 was mobile (able to move oneself) but gait (walking) was unsteady. A Health and Safety Code 1799 hold was in effect at the time of admission and Pt 8 was placed on alcohol withdrawal protocol. RN 18 stated the sedative medication Ativan was administered. RN 18 stated a fall risk assessment was not completed. RN 18 stated Pt 8 was not at risk for falling.

During a concurrent interview and record review, on 12/6/21, at 4:00 p.m., with the Interim Director of Emergency Department (IDED), the facility's policy and procedure titled, "Fall Precaution", dated 6/19 indicated, "Patients will be assessed for fall risks on admission, any change in level of care, after a fall, and every shift and as needed. Fall/safety assessment will be documented every 12 hours or with status change." Patients with a score of 45 -70 is high risk for fall. A plan of care is required for fall risk and/or fall prevention. The IDED stated a fall risk assessment and care plan should have been completed and implemented for Pt 8 on admission and during shift changes and were not. The IDED stated nursing staff assigned to care for Pt 8 did not complete a fall risk assessment and a care plan was not developed and implemented for Pt 8 on admission and during shift change. The IDED stated nursing staff completed a fall risk after Pt 8 fell on 11/25/21 at 2:52 p.m. but a care plan was not developed or implemented for Pt 8.

During an interview on 12/6/21, at 4:11 p.m., with ECT 2, ECT 2 stated he saw SG 2 on 11/25/21 outside Pt's 8 room saying Pt 8 fell. ECT 2 stated he did not witness Pt 8's fall but observed Pt 8 was on the floor on both knees and both hands on the floor. ECT 2 stated he saw blood coming from Pt 8's IV. ECT 2 stated he was assigned to provide 1:1 supervision on Pt 8 after the fall from 2:16 p.m. to 11:00 p.m. on 11/25/21. ECT 2 stated, "Pt 8 would periodically try to get out of bed (meaning a gurney) and had to be redirected." ECT 2 stated Pt. 8 was on a gurney. Both side rails (a guard device that serves as a barrier and attached to the side of the gurney) were up. ECT 2 stated Pt. 8 had a call light (a device used to signal hospital staff for assistance) and a urinal (a container used to collect urine) at the bedside. ECT 2 stated, "The 1:1 PSA's job duty was to keep the patient in direct line of sight at all times and document the activities of the patient every 15 minutes." ECT 2 stated Pt 8's activities were sleeping, sitting, vitals (blood pressure, heart rate, respiratory rate, oxygenation level [oxygen saturation percentage], and pain level), and nutritional intake. ECT 2 was unable to locate Pt 8's 1:1 PSA documentation for 11/25/21.

During a concurrent interview and record review, on 12/6/21, at 4:15 p.m., with the Interim Director of the Emergency Department (IDED), the facility's policy and procedure titled, "Alcohol Withdrawal: Care of the Patient" (alcohol withdrawal policy), dated 7/2018 was reviewed and indicated, "Screening and ongoing assessment are used to manage the symptoms of alcohol withdrawal." The IDED stated the alcohol withdrawal policy utilized "The Clinical Institute Withdrawal Assessment-Alcohol revised (CIWA-Ar)" tool which provided a method for measuring the severity of withdrawal symptoms (nausea and vomiting, tactile and visual disturbances, tremors, agitation, anxiety, headache, etc.) through a series of observations and questions and provided medical interventions (anxiolytics, sedation, intravenous fluid) for each corresponding score. A score of 0-6 required 2 hour assessments which included vital signs (blood pressure, respirations, heart rate, oxygen saturation level, and pain level). A score of 7-11 required 1 hour assessments. The IDED stated the following scores were documented by nursing staff in the clinical record for Pt 8: score of 11 on 11/25/21, at 12:26 a.m.; score of 7 on 11/25/21, at 2:31 a.m.; score of 8 on 11/25/21, at 4:58 a.m.; score of 11 on 11/25/21, at 9:48 a.m.; score of 9 on 11/25/21, at 12:28 p.m.; score of 0 on 11/25/21, at 8:00 p.m. but was entered on 11/26/21, at 12:27 a.m. The IDED confirmed the clinical record indicated Ativan (a sedative used to control agitation) 2 mg IV was administered on the following dates and times: 11/24/21 at 11:04 p.m.; 11/25/21 at 12:33 a.m.; 11/25/21 at 2:33 a.m.; 11/25/21 at 5:00 a.m.; 11/25/21 at 10:02 a.m.; 11/25/21 at 12:17 p.m.; 11/25/21 at 11:27 p.m. The IDED stated nursing staff assigned to care for Pt 8 did not document assessments of Pt 8 according to the "Alcohol Withdrawal: Care of the Patient" policy and procedure. The IDED stated 16 CIWA-Ar assessments were not completed as required. The IDED stated on 11/25/21, at 2:00 p.m., Pt 8 fell backward and struck the back of his head and the clinical record did not document assessments were conducted following the fall.

During an interview on 12/7/21, at 8:30 a.m., SG 2 stated on 11/25/21 at 2:00 p.m. SG 2 was patrolling (regular observation over an area for security purpose) the hospital when SG 2 was asked to retrieve a patient's belongings to the Behavioral unit of the ED. SG 2 stated he went to deliver the belongings when SG 2 saw Pt 8 attempting to get out of bed. Pt 8 was on a gurney (a stretcher with wheels used to transport patients). SG 2 stated Pt 8 was sitting up on the gurney. SG 2 passed the belongings to the fellow SG, looked back at Pt 8 and Pt 8 was at the end of the gurney with both feet dangling. Pt 8 stood up on to the floor. Pt 8's IV (intravenous tubing) was caught in the side rail of the gurney and SG 2 instructed Pt 8 to wait while SG 2 went to find a nurse to assist Pt 8. SG 2 stated while SG 2 was alerting the nurse outside of Pt 8's room, SG 2 saw Pt 8 turned to walk. SG 2 stated, "His IV tubing was caught in the rail and the IV tubing pulled him backwards." SG 2 stated Pt 8, "Landed flat on the floor on his back, then his head hit the ground." SG 2 stated he announced Pt 8 fell. SG 2 stated two nurses ran into Pt 8's room to assist Pt 8. SG 2 stated Pt 8 did not have a 1:1 sitter. SG 2 stated, "All could have been prevented had Pt 8 had a 1:1 sitter."

During an interview on 12/7/21, at 10:45 a.m., with RN 36, RN 36 stated she cared for Pt 8 in the ED on 11/24/21. RN 36 stated that Pt 8 was alert and oriented x3 (aware of person, place, and time) during Triage (the sorting of patients in the emergency room according to the urgency of needs). RN 36 stated Pt 8 followed commands, did not talk much, spoke English and Spanish but answered questions appropriately. RN 36 stated Pt 8 was able to get off the stretcher (a bed emergency medical services use to transport patients) without assistance and on to a wheelchair to be evaluated by a Medical Practitioner (a Doctor, Nurse Practitioner, or Physician Assistant). RN 36 stated a fall risk assessment was not completed at Triage because Pt 8 was not at risk for falling.

During an interview on 12/7/21, at 11:37 a.m., with RN 37, RN 37 stated she received report on Pt 8 from RN 21 on 11/25/21 at 8:00 p.m. RN 37 stated RN 21 informed RN 37 that Pt 8 had a fall earlier in the day around 2:00 p.m. and that Pt 8 required 1:1 supervision with a Patient Safety Attendant. RN 37 stated the Patient Safety Attendant was also providing 1:1 supervision on another patient on the unit during the same time. RN 37 stated, "The 1:1 supervision was inadequate but the department did what it could with the resources available." RN 37 stated a fall risk assessment was completed on Pt 8 after the fall but a care plan was not initiated because of time constraint and staffing shortage. RN 37 gave Pt 8 a Morse Fall Score of 60 which indicated "high risk" for falls. RN 37 completed one CIWA-Ar on Pt 8 with a score of zero. RN 37 stated Pt 8, "was very sedated." RN 37 stated she went to check on Pt 8 at 11:30 p.m. on 11/25/21 and saw that, "Pt 8's arms were stiff and contracted, and saturated with saliva and urine." RN 37 stated she suctioned (device used to remove secretions) Pt 8's mouth but Pt 8 was unresponsive (not responding). RN 37 stated, "Pt 8's pupils were disconjugate (not together) and unequal." RN 37 stated RN 37, "grabbed a nurse and called a physician to the bedside immediately." RN 37 stated Pt 8 was given Ativan 2mg IV for seizure precaution and taken to radiology for stat (meaning immediate) CT scan of the head. Pt 8 was transferred to the red zone (area of the ED for care of seriously ill patients) for acute care. RN 37 stated a CIWA-Ar score greater than 7 would require hourly assessments but RN 37 scored Pt 8 at a zero because Pt. 8 "was not exhibiting any of the withdrawal symptoms." RN 37 stated Pt 8 "was sedated." RN 37 stated the 1:1 PSA did not report any change of condition to RN 37. The CIWA-Ar score in the "Alcohol Withdrawal: Care of the patient" policy and procedure dated 7/2018 was reviewed with RN 37 which indicated, "a CIWA-Ar score of 0-6 required assessment every 2 hours." RN 37 stated, "I was busy with other patients."

During a record review of the "Post Fall Assessment Form" for Pt 8, dated 11/25/21, at 2:54 p.m., indicated that Pt 8's Morse Fall Score (a rapid method of assessing a patient's likelihood of falling) was 60.

During a review of the clinical record for Pt 8 indicated an individual plan of care was not initiated for Pt 8 throughout his hospital stay in the ED.

During a review of the facility's policy and procedure titled, "Behavioral Health," dated 2/2021, the P&P indicated, "Purpose: To provide mental health screening/assessment and care to patients who present as a possible danger to themselves, danger to others, or are gravely disabled as a result of a mental disorder to ensure that they are provided a safe environment and continuum of care to address their specific needs ... E. A 1:1 PSA shall be with a High-Risk patient at all time, in the room or doorway and able to reach the patient within 15 seconds. The PSA will accompany the patient to the bathroom and observe at all times. The PSA completes the Restraints/PSA Plan of Care, documenting every 15 minutes on observed behaviors."

During a review of the facility's policy and procedure titled, "Fall Precaution," dated 6/2019, the P&P indicated, "Purpose: To provide guidelines to identify patients at risk for falls, implement interventions, and reduce the risk of patient harm resulting from falls ... 2. Patients will be assessed for fall risk as follows: On admission, any change in level of care, i.e., surgery or transfer to a critical care, after a fall, every shift and PRN (as needed) ... G. 2) Score 45-70: High Risk Fall. Initiate IPOC (Individual Plan of Care) for fall risk and/or fall prevention ..."

During a review of the facility's policy and procedure titled, "Alcohol Withdrawal: Care of the Patient", dated 7/2018, indicated, "Screening and ongoing assessment are used to manage the symptoms of alcohol withdrawal ... RN assesses patient using Clinical Institute Withdrawal Assessment-Alcohol revised (CIWA-Ar) tool and provides medical intervention per CIWA-Ar criteria ... 4. Interventions based on patient CIWA-Ar score ... Score of 0-6 assess every 2 hours x3 (6 hours) then assess every 4 hours x2 (8 hours). No medications. Score of 7-11 assess every 1 hour. Medication dosing: 2 mg Ativan IV or PO, 32.4 mg Phenobarbital PO. 30 mg Phenobarbital IV. 25 mg Chordiazepoxide PO ..."

During a review of professional reference, Nursing 2020 Critical Care, September 2019 - Volume 14 - Issue 5 - p 18-30 (Caring for hospitalized patients with alcohol withdrawal syndrome),
https://journals.lww.com/nursingcriticalcare/fulltext/2019/09000/caring_for_hospitalized_patients_with_alcohol.3.aspx, the professional reference indicated, " ...Current recommendations for evidence-based nursing interventions during alcohol withdrawal include the following: Ensure a patent airway; suction as needed; frequently monitor vital signs, observing for respiratory distress; use individualized symptom-triggered therapy; assess skin for abnormalities such as jaundice, pressure injuries, rashes, signs of dehydration, and ecchymoses; inspect for needle tracks from I.V. drug use; use the CIWA-Ar tool to guide medication administration with benzodiazepines; Encourage the patient to rest by controlling minimal interpersonal contact with the patient. Decrease environmental stimuli with controlled lighting, and provide a calm, quiet private room; provide adequate nutrition and fluid intake. Obtain a dietary consult as indicated to treat malnutrition. Administer thiamine (I.V., I.M. for absorption) to prevent Wernicke-Korsakoff syndrome and Wernicke encephalopathy, and additional vitamins (folate) as prescribed; document fluid intake and output. Maintain I.V. access and administer I.V. fluids as prescribed; review all lab results and closely monitor for illicit drugs, opioids, electrolyte imbalances, including hypomagnesemia, hypokalemia, and hypophosphatemia. Also watch for liver biochemical test abnormalities, including serum aspartate aminotransferase, alanine aminotransferase, and gamma glutamyl transferase. A serum carbohydrate-deficient transferrin level can identify chronic heavy alcohol consumption.29 Ethyl glucuronide is a biomarker for recent alcohol consumption; assess mental status, suicide risk (up to 15% of AUD patients are at risk for death), sleep pattern, and provide emotional support to reduce anxiety. Reassure the patient that depressive symptoms and sleep disturbances during withdrawal are common but temporary; control agitation; control seizures."

The facility failed to meet the regulatory requirements for the Condition of Participation: CFR 482.23 Nursing Services as evidenced by the following:

1. Based on interview and record review, the facility failed to ensure licensed nurses adhered to the facility's policies and procedures (P&Ps) when six of seven sampled patients' (Patients 1, 3, 4, 5, 6, and 7) vital signs (measurements are taken to help assess the general physical health of a person, give clues to possible diseases, and show progress toward recovery) were not completed in accordance with the patients' Emergency Severity Index (ESI- a five-level emergency department [ED] triage [process of determining the severity of a patient's condition] algorithm [a step-by-step set of instructions for solving a problem or performing a task] that provides clinically relevant stratification [the arrangement or classification of individuals into different groups] of patients into five groups from 1 [most urgent] to 5 [least urgent] on the basis of acuity and resource needs) level upon triage, per the facility's P&P titled, "Documentation, Emergency Department".

This failure resulted in Patients 1, 3, 4, 5, and 7's vital signs to not be obtained which had the potential for their condition to change and the licensed nurses to not be able to intervene in a timely manner. (Refer to A-0398, Finding 1)

2. Based on interview and record review, the facility failed to ensure licensed nurses adhered to the facility's P&Ps when three of seven sampled patients' (Patients 1, 4, and 7) "full assessment" (complex multisystem assessment completed by the registered nurse) were not completed per the facility's P&P titled, "Documentation, Emergency Department".

This failure resulted in Patients 1, 4, and 7's full assessment to not be completed which had the potential for any changes to go undetected. (Refer to A-0398, Finding 2)

3. Based on interview and record review, the facility failed to ensure licensed nurses adhered to the facility's P&Ps when three of seven sampled patients' (Patients 1, 4, and 7) communication report (SBAR- Situation, Background, Assessment, Recommendation; a technique used to facilitate prompt and appropriate communication) was not completed per the facility's P&P titled, "Documentation, Emergency Department".

This failure resulted in Patients 1, 4, and 7's SBAR to not be completed which had a potential to affect the continuity of care of patients. (Refer to A-0398, Finding 3)

4. Based on interview and record review, the facility failed to administer medications in accordance with the practitioner's orders and the staff failed to conduct assessment/reassessments per the facility's P&P when one of seven sampled patients (Patient 1) did not receive pain medication in accordance with the physician's order during the Emergency Department (ED) encounter.

This failure resulted in adequate medical treatment for Patient 1; Patient 1 remained in severe pain during the ED encounter. (Refer to A-0405, Finding 1)

5. Based on interview and record review, the facility failed to administer medications in accordance with the practitioner's orders and the staff failed to conduct assessment/reassessments per the facility's P&P when three of seven sampled patients (Patients 5, 6, and 7) did not receive their prescribed medications in a timely manner.

This failure resulted in delayed medication administration for Patients 5, 6, and 7, which had the potential to cause harm. (Refer to A-0405, Finding 2)

6. Based on interview and record review, the hospital failed to administer medications in accordance with the practitioner's orders and the staff failed to conduct assessment/reassessments per the facility's P&P when four of seven sampled patients (Patients 2, 5, 6, and 7) were administered pain medication, and their pain was not reassessed per the facility's P&P titled, "Pain Management Guidelines".

This failures had the potential for Patients 2, 5, 6, and 7 to continue to be in pain and to not have their needs reassessed in a timely manner. (Refer to A-0405, Finding 3)

The cumulative effect of these systemic problems resulted in the facility' s inability to ensure the provision of quality health care, in compliance with the Condition of Participation for Nursing Services.

Based on interview and record review, the facility failed to ensure licensed nurses adhered to the facility's policies and procedures (P&Ps) when:

1. Six of seven sampled patients' (Patients 1, 3, 4, 5, 6, and 7) vital signs (measurements are taken to help assess the general physical health of a person, give clues to possible diseases, and show progress toward recovery) were not completed in accordance with the patients' Emergency Severity Index (ESI- a five-level emergency department [ED] triage [process of determining the severity of a patient's condition] algorithm [a step-by-step set of instructions for solving a problem or performing a task] that provides clinically relevant stratification [the arrangement or classification of individuals into different groups] of patients into five groups from 1 [most urgent] to 5 [least urgent] on the basis of acuity and resource needs) level upon triage, per the facility's P&P titled, "Documentation, Emergency Department".

This failure resulted in Patients 1, 3, 4, 5, and 7's vital signs to not be obtained which had the potential for their condition to change and the licensed nurses to not be able to intervene in a timely manner.

2. Three of seven sampled patients' (Patients 1, 4, and 7) "full assessment" (complex multisystem assessment completed by the registered nurse) were not completed per the facility's P&P titled, "Documentation, Emergency Department".

This failure resulted in Patients 1, 4, and 7's full assessment to not be completed which had the potential for any changes to go undetected.

3. Three of seven sampled patients' (Patients 1, 4, and 7) communication report (SBAR- Situation, Background, Assessment, Recommendation; a technique used to facilitate prompt and appropriate communication) was not completed per the facility's P&P titled, "Documentation, Emergency Department".

This failure resulted in Patients 1, 4, and 7's SBAR to not be completed which had a potential to affect the continuity of care of patients.

Findings:

1. During a concurrent interview and record review on 11/24/21 at 1:28 p.m., with the Emergency Department Manager (EDM), Pt 1's electronic clinical records were reviewed. The EDM stated she was familiar with Pt 1's ED encounter and validated Pt 1 came to ED on 9/16/21 at 11:50 p.m. and was categorized as ESI of 3 (urgent). The EDM validated between 9/16/21 at 11:51 p.m. through 9/17/21 at 8:31 a.m., Pt 1's vital signs were not completed. The EDM stated vital signs were not conducted for eight consecutive hours while Pt 1 was cared for in the ED. The EDM stated four sets of vital signs were not completed by RNs for Pt 1. The EDM stated the expectation was for nurses to obtain vital signs every 2 (two) hours for patients with an ESI level of 2 (emergent) and 3. The EDM stated the purpose of obtaining vital signs was to assess patients appropriately, keep patients safe, and implement other interventions as necessary or to determine the next intervention in response to abnormal vital signs. The EDM stated Pt 1 had a surgical procedure and staff should have ensured there were no complications from the surgical procedure. The EDM reviewed the hospital's P&P titled "Documentation, Emergency Department" and stated the P&P should have been followed.

During a review of Pt 1's "ED Adult Triage Form" dated 9/16/21, the ED Adult Triage Form indicated, " ...Chief Complaint- Triage: Urinary Retention, hematuria (the presence of blood in a person's urine) ... Track Acuity: 3 Urgent ..."

During a review of Patient (Pt) 1's "History and Physical" (H&P), dated 9/17/21, the H&P indicated, " ... CHIEF COMPLAINT: Hematuria (the presence of blood in a person's urine) blocked catheter (tube that is inserted into the bladder) ...HISTORY OF PRESENT ILLNESS ...85 years old male came to the emergency room complaining of blocked Foley catheter (flexible tube placed in the bladder to drain urine ) ... Patient had TURP (transurethral resection of the prostate- surgery to remove parts of the prostate gland [walnut-sized gland located between the bladder and the penis] through the penis) done by patient urologist (physician diagnoses and treats diseases of the urinary tract system) and patient has indwelling (placed or implanted within the body) Foley catheter ... Foley catheter was not draining and draining blood clots so he comes to the emergency room ... Patient being hospitalized for further evaluation continuous bladder irrigation (procedure to open a plugged catheter) and follow-up urology consultation ... Vital Signs (measurements taken to help assess the general physical health of a person, give clues to possible diseases, and show progress toward recovery): Temperature: 37.1 (09/16 23:48 [11:48 p.m.]) ... Pulse: 110 (pulse for healthy adults ranges from 60 to 100 beats per minute) (09/16 23:48 [11:48 p.m.]) ... Respiration: 18 (09/16 23:48 [11:48 p.m.) ... BP (blood pressure- amount of blood your heart pumps and the amount of resistance to blood flow in your arteries) : 184/90 (normal blood pressure for most adults is defined as a systolic pressure of less than 120 and a diastolic pressure [top number] of less than 80 [bottom number]) (09/16 23:48 [11:48 p.m.]) ... Pulse Ox (oximetry- measuring of the percentage of oxygen-saturated hemoglobin in the blood): 98 (09/16 23:48 [11:48 p.m.]) ... Pain Score: 10 (pain scale is a numerical scale from 0 to 10. 0 means no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) (09/16 23:50 [11:50 p.m.]) ... "

During a concurrent interview and record review on 11/29/21 at 11:17 a.m., with Registered Nurse (RN) 4, Pt 1's electronic clinical records were reviewed. RN 4 stated he cared for Pt 1 and validated on 9/16/21, Pt 1 was triaged as an ESI of 3 and four sets of vital signs were not completed by RNs. RN 4 stated patients with an ESI of 3 should have their vital signs taken every two hours. RN 4 stated he did not recall obtaining Pt 1's vital signs and stated he should have. RN 4 stated vital signs have to be obtained to monitor patients' hemodynamic (refers to basic measures of heart function) status and to compare it to patients' base line (normal for patient) to determine any risk of worsening condition.

During a concurrent interview and record review on 12/1/21 at 2:50 p.m., with RN 1, Pt 1's electronic clinical records were reviewed. RN 1 stated he cared for Pt 1 and validated four sets of vital signs were not completed by RNs. RN 1 stated for patients with an ESI level of 3, RNs should have taken vital signs every two hours. RN 1 validated Pt 1's vital signs were obtained during triage (9/16/21 at 11:48 p.m.) and were not retaken during the entire ED encounter, (9/16/21 at 11:48 p.m. to 9/17/21 at 8:31 a.m., a total of eight hours and 41 minutes). RN 1 stated vital signs have to be documented to monitor patients' hemodynamic status to compare it to the base line and to determine any risk for potential worsening condition of patient and for patient safety and to validate he have done the task.

During a concurrent interview and record review on 12/1/21, at 10:45 a.m., with the Emergency Department Interim Direction (EDID), Pt 3's electronic clinical records were reviewed. The EDID stated she was familiar with Pt 3's ED encounter and validated Pt 3 came to ED on 11/22/21 at 9:35 p.m. and was categorized as an ESI of 3 (Urgent). The EDID stated Pt 3's vital signs were not completed every two hours. The EDID stated RNs did not complete vital signs at 2 a.m. (11/23/21). The EDID stated the RN should have completed vital signs every two hours for patient safety.

During a review of Pt 3's "ED Adult Triage Form" dated 11/22/21, the ED Adult Triage Form indicated, " ...Chief Complaint Triage: Fall, L [left] lateral (side) rib pain ...Track Acuity: 3 Urgent ..."

During a review of Pt 3's "ED Physician Notes", dated 11/22/21, the ED Physician Notes indicated, " ...Time seen: Date & time 11/22/2021 21:34 [9:34 p.m.] ... History of Present Illness ...Brief History: 58 y/o (year old) male presents to the ED with left sided rib pain s/p (status post) fall on 11/20/2021. Pt states his right knee had given out which caused him to fall ... When he fell, the pt mentions he hit the corner of a 'marble counter'. His pain has been getting worse since his fall. Additionally, the pt mentions having some SOB (shortness of breath) secondary to his pain and bruising to his right abdomen. Denies fever, chill ... ROS (review of systems): SOB, Rib pain, Fall, Right knee pain ... Vital signs 11/22/2021 21:30 [9:30 p.m.] ... Temperature ... 36.7 Degrees C (Celsius- a unit of temperature) ... Pulse rate 75 BPM (beats per minute) ... Respiratory Rate 17 Br PM (breaths per minute) ... Pulse Oximetry 95% (percent- unit of measurement) ... Systolic BP 185 mmHg (millimeter of mercury- unit of measurement) ... Diastolic BP 106 mmHg ..."

During a concurrent interview and record review on 12/2/21 at 2:26 p.m., with RN 7, Pt 4's electronic clinical records were reviewed. RN 7 stated she was familiar with Pt 4's ED encounter and validated Pt 4 came to ED on 11/23/21 at 10:10 a.m. and was categorized as an ESI of 3 (Urgent). Pt 4's vital signs were not completed every two hours. RN 7 stated the RN did not complete the vital signs scheduled on 12:10 p.m. (11/23/21). RN 7 stated vital signs should have been monitored for them [healthcare team] to determine the trend of the patients, such as if a patient's blood pressure was elevated. RN 7 stated obtaining vital signs were important to ensure we [healthcare team] managed patients' care and for the patient's safety. RN 7 stated vital signs should have been completed in accordance with hospital's P&P to ensure patients were assessed appropriately and to inform the physician about the patient's condition, to treat patients appropriately and to keep patients safe.

During a review of Pt 4's "ED Adult Triage Form" dated 11/23/21, the ED Adult Triage Form indicated, " ...Chief Complaint- Triage: low abd [abdominal] pain ...Track Acuity: 3 Urgent ..."

During a review of Pt 4's "ED Physician Notes", dated 11/23/21, the ED Physician Notes indicated, " ...Time seen: Date & time 11/23/2021 10:17 [a.m.] ... History of Present Illness ... Brief History: This patient is a 49 y/o female that presents to the ED with c/o (complaints of) lower abdominal pain and R (right) flank (side of body between the ribs and the hip) pain onset 3 days ago with gradual worsening. Describes her pain as muscle spasms (involuntary muscular contraction). She notes that when she wakes up her pain will be worse and describes it as a tightening. Denies fever, chills, dysuria (pain or a burning sensation when you pee), vaginal itching, vaginal odor, vaginal discharge, and hematuria. Denies recent injury. Denies h/o (history of) abdominal surgeries and h/o kidney infection/stones. Denies currently taking blood thinners. Of note, patient has a ride home ... ROS: (+) (positive) abdominal pain, flank pain (-) (negative) fever, chills, dysuria, vaginal itching, vaginal odor, vaginal discharge, hematuria ... Vital Signs ... 11/23/2021 10:10 [a.m.] ... Temperature Celsius 36.6 Degrees C ... Pulse Rate 83 BPM ... Respiratory Rate 18 Br PM ...Pulse Oximetry 97%...Systolic BP 110 mmHg ...Diastolic BP 61 mmHg ..."

During a concurrent interview and record review on 12/1/21, at 10:35 a.m., with the Risk Management Coordinator (RMC), Pt 5's clinical records were reviewed. The EDM stated she was familiar with Pt 5's ED encounter and validated Pt 5 was triage in ED as an ESI level 2 (emergent) on 11/1/21 at 2:56 a.m. The RMC stated vital signs should have been completed every two hours for patients that were categorized as ESI 2 and 3. The RMC stated vital signs were not completed from 11/1/21 at 2:56 a.m. to 11/1/21 at 12:28 p.m., (total of nine hours and 32 minutes). The RMC validated four sets of vital signs were not completed by the RNs.

During a review of Pt 5's "ED Adult Triage Form" dated 11/1/21, the ED Adult Triage Form indicated, " ...Chief Complaint- Triage: Urinary retention ...Track Acuity: 2 Emergent ..."

During a review of Pt 5's "History and Physical", dated 11/1/21, the H&P indicated, " ...CHIEF COMPLAINT: Dysuria x (for) 5 days ... HISTORY OF PRESENT ILLNESS: 58 year old Spanish speaking male with past medical history of BPH (Benign prostatic hyperplasia- is a common condition as men get older. An enlarged prostate gland can cause uncomfortable urinary symptoms, such as blocking the flow of urine out of the bladder. It can also cause bladder, urinary tract or kidney problems) and bladder calculi (stone), mass presented with dysuria x 5 days. Symptoms have been progressively worsening. Associated with non radiating lower abdominal pain 5/10 in intensity, hematuria, and increased frequency in urination. Patient states that his symptoms were manageable until yesterday when he was returning from his one day trip to Mexico. Patient was on the airplane when he started experiencing difficulty in urination and started passing blood. After that he was not able to urinate at all. Associated with fever and chills. He was given [brand name of acetaminophen (pain and fever reliever medication)] and tramadol (pain reliever to treat moderate to moderately serve pain), which resulted in slight relief of symptoms. Denies nausea, vomiting, or urinary incontinence (the loss of bladder control) ..."

During a concurrent interview and record review on 12/1/21 at 2:03 p.m., with RN 10, Pt 6's electronic health records were reviewed. RN 10 stated she was familiar with Pt 6's ED encounter and validated Pt 6 was triage in the ED as an ESI level 3 (urgent) on 11/1/21 at 10:10 a.m. RN 10 stated vital signs should have been completed every two hours for patients with an ESI level 2 and 3. RN 10 stated there were two sets of vital signs that were not completed, 11/1/21 at 1:36 p.m. and 11/1/21 at 3:36 p.m.

During a review of Pt 6's "ED Adult Triage Form" dated 11/1/21, the ED Adult Triage Form indicated, " ...Chief Complaint- Triage: uti (urinary tract infection- bladder infection) symptoms ...Track Acuity: 3 Urgent ..."

During a review of Pt 6's "ED Physician Notes", dated 11/1/21, the ED Physician Notes indicated, " ...Time seen: Date & time 11/01/2021 11:14 [a.m] ... History of Present Illness 53 y/o Hmong- speaking male presents to the ED c/o generalized 9/10 penile pain x3 days. Pt states the pain exacerbates (worsens) when urinating and radiates from his penis to scrotum (in the male reproductive system) and rectum and finally to lower back ... Denies any hematochezia (blood in stool), hematuria, ... Pt notes the pain is most remarkable while laying down. He has taken 800 mg ibuprofen (drug used to treat fever, swelling, pain, and redness by preventing the body from making a substance that causes inflammation) to momentary relief of sx (symptoms) ..."

During a concurrent interview and record review on 12/1/21 at 2:55 p.m., with RN 1, Pt 7's electronic clinical record were reviewed. RN 1 stated he was familiar with Pt 7's ED encounter and validated Pt 7 was triage in ED with an ESI level 2 (emergent) on 11/2/21 at 2:24 a.m. RN 1 stated vital signs should have been completed every two hours for patients with an ESI level of 2 or 3. RN 1 stated two sets of vital signs were not completed, 11/2/21 at 4:24 a.m. and 11/2/21 at 6:16 a.m.

During a review of Pt 7's "ED Adult Triage Form" dated 11/2/21, the ED Adult Triage Form indicated, " ...Chief Complaint- Triage: Voiding (urinate) dysfunction (abnormality or impairment in the function) ...Track Acuity: 2 Emergent ..."

During a review of Pt 7's "ED Physician Notes", dated 11/2/21, the ED Physician Notes indicated, " ...Time seen: Date & time 11/02/2021 02:23 [a.m.] ... History of Present Illness 65-year-old Spanish and English speaking male presents complaining of severe difficulty urinating. He can only urinate some drops. He underwent bilateral (both sides) inguinal (groin) herniorrhaphy (type of hernia repair surgery where a mesh patch is sewn over the weakened region of tissue) yesterday, 11/1/2021 ... Vital Signs ... 11/2/2021 02:24 [a.m.] ... Temperature ... 36.7 Degrees C ... Pulse rate 71 BPM ...Respiratory Rate 18 Br PM ...Pulse Oximetry 95%... Systolic BP 130 mmHg ...Diastolic BP 60 mmHg ... Pain score 10 ..."

During a concurrent interview and record review on 11/24/21 at 10:20 a.m., with the EDID, Pts 1, 3, and 4's electronic clinical records were reviewed. The EDID stated she was familiar with Pt 1, Pt 3 and Pt 4's ED encounters and the RNs did not complete vital signs every two hours as evidence documented in the electronic clinical records. The EDID stated RNs should have taken patients' vital signs every two hours and documented the data in the clinical records. The EDID stated vital signs identified and provided RNs vital information on how the patients' were doing hemodynamically and to compare baseline vital signs to current vital signs to detect or monitor any medical problems patients experienced.

During a concurrent interview and record review on 12/3/21 at 8:39 a.m., with the RMC, Pts 5, 6 and 7's electronic clinical records were reviewed. The RMC stated she reviewed Pt 5, Pt 6 and Pt 7's ED encounters and validated RNs did not complete vital signs every two hours as evidence documented in the electronic clinical records. The RMC stated RNs should have taken patients' vital signs every two hours and documented the data in the clinical records. The RMC stated vital signs provided nurses information about the patients to identify any issues patients may be experiencing, and for nurses to manage patients in a timely manner.

During a review of the facility's P&P titled, "Documentation, Emergency Department," dated January 2019, the P&P indicated, " ...PURPOSE: Charting guidelines for the Emergency Department (ED). To Outline the responsibilities of the healthcare team member in documenting the status of a patient during their ED visit ... OUTCOME: A record of the patients Emergency Department visit are to be documented from admission to discharge ... Frequency of ongoing assessment/documentation will be based on patient acuity and the desired responses to interventions ... Documentation will be completed by the following: RN, LVN (Licensed Vocational Nurse) and Emergency Clinical Technicians ... Nursing physical assessment will include objective and subjective data (statements made by the patient and family about condition) ...Absolute Requirements ... 1) Assessment ...a) A full assessment will be performed on all ESI level 1, 2 and 3 at the beginning of each shift, with each handover of care to a new primary care RN ... 2.) Vital signs ... Every 2 hours for all ESI level 2, 3 unless otherwise ..."

2. During a concurrent interview and record review with the EDID, on 11/24/21 at 10:20 a.m., Pt 1's electronic clinical records were reviewed. The EDID stated she was familiar with Pt 1's ED encounter and validated Pt 1 came to ED on 9/16/21 at 11:50 p.m. and was triaged as an ESI level 3 (urgent). For Pt 1, RNs did not complete a full assessment with each handover (report given for continuity of care between nurses) to the new assigned RN. The EDID stated a full assessment should be completed by the RNs for all patients with an ESI level of 1, 2 and 3 at the beginning of each shift and with each handover of care to a new primary care nurse to identify baseline condition and understand the needs of patients and to ensure safe and effective care was provided to keep patient safe.

During a review of Pt 1's "ED Adult Triage Form" dated 9/16/21, the ED Adult Triage Form indicated, " ...Chief Complaint- Triage: Urinary Retention, hematuria ...Track Acuity: 3 Urgent ..."

During a review of Pt 1's "History and Physical", dated 9/17/21, the H&P indicated, " ... CHIEF COMPLAINT: Hematuria blocked catheter ...HISTORY OF PRESENT ILLNESS ...85 years old male came to the emergency room complaining of blocked Foley catheter ... Patient had done by patient urologist and patient has indwelling Foley catheter ... Foley catheter was not draining and draining blood clots so he comes to the emergency room ... Patient being hospitalized for further evaluation continuous bladder irrigation and follow-up urology consultation ... Vital Signs: Temperature: 37.1 (09/16 23:48 [11:48 p.m.]) ... Pulse: 110 (09/16 23:48 [11:48 p.m.]) ... Respiration: 18 (09/16 23:48 [11:48 p.m.) ... BP : 184/90 (09/16 23:48 [11:48 p.m.]) ... Pulse Ox: 98 (09/16 23:48 [11:48 p.m.]) ... Pain Score: 10 (out of 10) (09/16 23:50 [11:50 p.m.]) ... "

During a concurrent interview and record review with the EDID, on 11/24/21 at 10:20 a.m., Pt 4's electronic clinical records were reviewed. The EDID stated she was familiar with Pt 4's ED encounter and validated Pt 4 came to ED on 11/23/21 at 10:10 a.m. and was categorized as an ESI level 3 (urgent). For Pt 4, RNs did not complete a full assessment with each handover of care to the new primary care RN. The EDID stated a full assessment should be completed by the RNs for all patients with an ESI level 1, 2 and 3 at the beginning of each shift and with each handover of care to new primary care nurse to identify baseline condition and understand the needs of patients and to ensure safe and effective care was provided to keep patient safe.

During a review of Pt 4's "ED Adult Triage Form" dated 11/23/21, the ED Adult Triage Form indicated, " ...Chief Complaint- Triage: low abd [abdominal] pain ...Track Acuity: 3 Urgent ..."

During a review of Pt 4's "ED Physician Notes", dated 11/23/21, the ED physician Notes indicated, " ...Time seen: Date & time 11/23/2021 10:17 [a.m.] ... History of Present Illness ... Brief History: This patient is a 49 y/o female that presents to the ED with c/o lower abdominal pain and R [right] flank pain onset 3 days ago with gradual worsening. Describes her pain as muscle spasms. She notes that when she wakes up her pain will be worse and describes it as a tightening. Denies fever, chills, dysuria, vaginal itching, vaginal odor, vaginal discharge, and hematuria. Denies recent injury. Denies h/o abdominal surgeries and h/o kidney infection/stones. Denies currently taking blood thinners. Of note, patient has a ride home ... ROS: (+) abdominal pain, flank pain(-) fever, chills, dysuria, vaginal itching, vaginal odor, vaginal discharge, hematuria ... Vital Signs ... 11/23/2021 10:10 [a.m.] ... Temperature Celsius 36.6 Degrees C ... Pulse Rate 83 BPM ... Respiratory Rate18 Br PM ... Pulse Oximetry 97%... Systolic BP 110 mmHg ... Diastolic BP 61 mmHg ..."

During a concurrent interview and record review on 12/3/21, at 8:39 a.m., with the RMC, Pt 7's electronic clinical records were reviewed. The RMC stated she reviewed the Pt 7's ED encounter and validated Pt 7 was triage in ED as an ESI level 2 (emergent) on 11/2/21 at 2:24 a.m.. Pt 7's RNs did not complete a full assessment with each handover of care to the new primary care RN. The RMC stated full assessment should be completed by the RNs with each handover of care the new primary care RN to identify baseline condition and understand the needs of patients and to ensure safe and effective care was provided to keep patient safe.

During a review of Pt 7's "ED Adult Triage Form" dated 11/2/21, the ED Adult Triage Form indicated, " ...Chief Complaint- Triage: Voiding (urinate) dysfunction (abnormality or impairment in the function) ...Track Acuity: 2 Emergent ..."

During a review of Pt 7's "ED Physician Notes", dated 11/2/21, the ED Physician Notes indicated, " ...Time seen: Date & time 11/02/2021 02:23 [a.m.] ... History of Present Illness 65-year-old Spanish and English speaking male presents complaining of severe difficulty urinating. He can only urinate some drops. He underwent bilateral inguinal herniorrhaphy yesterday, 11/1/2021 ... Vital Signs ... 11/2/2021 02:24 [a.m.] ... Temperature ... 36.7 Degrees C ... Pulse rate 71 BPM ... Respiratory Rate 18 Br PM ... Pulse Oximetry 95%... Systolic BP 130 mmHg ... Diastolic BP 60 mmHg ... Pain score 10 ..."

During a review of the facility's P&P titled, "Documentation, Emergency Department," dated January 2019, the P&P indicated, " ...PURPOSE: Charting guidelines for the Emergency Department (ED). To Outline the responsibilities of the healthcare team member in documenting the status of a patient during their ED visit ... OUTCOME: A record of the patients Emergency Department visit are to be documented from admission to discharge ... DEFINITIONS: ... Full Assessment: Complex multisystem assessment completed by the RN, not the Quick Look Triage (QLT) nurse. This exam may be completed at the bedside, or in the Vertical Care Area ... Frequency of ongoing assessment/documentation will be based on patient acuity and the desired responses to interventions ... Documentation will be completed by the following: RN, LVN and Emergency Clinical Technicians ... Nursing physical assessment will include objective and subjective data (statements made by the patient and family about condition) ...Absolute Requirements ... 1) Assessment ...a) A full assessment will be performed on all ESI level 1, 2 and 3 at the beginning of each shift, with each handover of care to a new primary care RN ..."

3. During a review of Pt 1's "History and Physical", dated 9/17/21, the H&P indicated, " ... CHIEF COMPLAINT: Hematuria blocked catheter ...HISTORY OF PRESENT ILLNESS ...85 years old male came to the emergency room complaining of blocked Foley catheter ... Patient had done by patient urologist and patient has indwelling Foley catheter ... Foley catheter was not draining and draining blood clots so he comes to the emergency room ... Patient being hospitalized for further evaluation continuous bladder irrigation and follow-up urology consultation ... Vital Signs: Temperature: 37.1 (09/16 23:48 [11:48 p.m.]) ... Pulse: 110 (09/16 23:48 [11:48 p.m.]) ... Respiration: 18 (09/16 23:48 [11:48 p.m.) ... BP : 184/90 (09/16 23:48 [11:48 p.m.]) ... Pulse Ox: 98 (09/16 23:48 [11:48 p.m.]) ... Pain Score: 10 (out of 10) (09/16 23:50 [11:50 p.m.]) ... "

During a concurrent interview and record review on 11/24/21 at 10:20 a.m., with the EDID, Pt 1's electronic clinical records were reviewed. The EDID stated she was familiar with Pt 1's ED encounter and validated the RNs did not complete SBAR (handoff) during the transition of care to another nurse. The EDID stated the SBAR form should have been completed by the RNs when transitioning the care of the patient to another nurse to identify baseline condition and understand the needs of patients and to ensure safe and effective care was provided to keep patient safe.

During a review of Pt 4's "ED Physician Notes", dated 11/23/21, the ED physician Notes indicated, " ...Time seen: Date & time 11/23/2021 10:17 [a.m.] ... History of Present Illness ... Brief History: This patient is a 49 y/o female that presents to the ED with c/o lower abdominal pain and R [right] flank pain onset 3 days ago with gradual worsening. Describes her pain as muscle spasms. She notes that when she wakes up her pain will be worse and describes it as a tightening. Denies fever, chills, dysuria, vaginal itching, vaginal odor, vaginal discharge, and hematuria. Denies recent injury. Denies h/o abdominal surgeries and h/o kidney infection/stones. Denies currently taking blood thinners. Of note, patient has a ride home ... ROS: (+) abdominal pain, flank pain(-) fever, chills, dysuria, vaginal itching, vaginal odor, vaginal discharge, hematuria ... Vital Signs ... 11/23/2021 10:10 [a.m.] ... Temperature Celsius 36.6 Degrees C ... Pulse Rate 83 BPM ... Respiratory Rate18 Br PM ... Pulse Oximetry 97%... Systolic BP 110 mmHg ... Diastolic BP 61 mmHg ..."

During a concurrent interview and record review with the EDID, on 11/24/21 at 10:20 a.m., Pt 4's electronic clinical records were reviewed. The EDID stated she was familiar with Pt 4's ED encounter and validated for Pt 4, the RNs did not complete a SBAR form when they transitioned the care of the patient to another nurse. The EDID stated SBAR should have been completed by the RNs when transitioning the care of the patient to another nurse to understand who was responsible to patients care and key components of care is handed off to the incoming primary care RN.

During a review of Pt 7's "ED Physician Notes", dated 11/2/21, the ED Physician Notes indicated, " ...Time seen: Date & time 11/02/2021 02:23 [a.m.] ... History of Present Illness 65-year-old Spanish and English speaking male presents complaining of severe difficulty urinating. He can only urinate some drops. He underwent bilateral inguinal herniorrhaphy yesterday, 11/1/2021 ... Vital Signs ... 11/2/2021 02:24 [a.m.] ... Temperature ... 36.7 Degrees C [ Celsius is a unit of temperature on the Celsius scale] ... Pulse rate 71 BPM [beats per minute] ... Respiratory Rate 18 Br PM [breaths per minute] ... Pulse Oximetry 95%... Systolic BP 130 mm Hg ... Diastolic BP 60 mmHg ... Pain score 10 ..."

During a concurrent interview and record review on 12/3/21 at 8:39 a.m., with the RMC, Pt 7's electronic clinical records were reviewed. The RMC stated she reviewed Pt 7's ED encounter and validated RNs did not complete SBAR when they transitioned the care of Pt 7 to another nurse. The RMC stated SBAR should have been completed by the RNs when they turned over the care of the patient to another nurse to understand who was responsible for the patient's care and to continue care by the incoming primary care RN.

During a review of the facility's P&P titled, "Documentation, Emergency Department," dated January 2019, the P&P indicated, " ...PURPOSE: Charting guidelines for the Emergency Department (ED). To Outline the responsibilities of the healthcare team member in documenting the status of a patient during their ED visit ... Documentation will be completed by the following: RN, LVN and Emergency Clinical Technicians ... Absolute Requirements ... The ad-hoc (when necessary or needed) form (SBAR) will be completed by the RN/LVN when turning over care of the patient to another RN ... "

Based on interview and record review, the facility failed to administer medications in accordance with the practitioner's orders and the staff failed to conduct assessment/reassessments per the facility's policies and procedures (P&P) when:

1. One of seven sampled patients (Patient 1) did not receive pain medication in accordance with the physician's order during the Emergency Department (ED) encounter.

This failure resulted in adequate medical treatment for Patient 1; Patient 1 remained in severe pain during the ED encounter.

2. Three of seven sampled patients (Patients 5, 6, and 7) did not receive their prescribed medications in a timely manner.

This failure resulted in delayed medication administration for Patients 5, 6, and 7, which had the potential to cause harm.

3. Four of seven sampled patients (Patients 2, 5, 6, and 7) were administered pain medication, and their pain was not reassessed per the facility's P&P titled, "Pain Management Guidelines".

This failures had the potential for Patients 2, 5, 6, and 7 to continue to be in pain and to not have their needs reassessed in a timely manner.

4. One of seven sampled patients (Patient 3) received a narcotic (substance used to treat moderate to severe pain) for pain management, and their respiration rate (the number of breaths a person takes per minute) was not assessed per the facility's P&P titled, "Pain Management Guidelines".

This failure resulted in Patient 3's respiratory rate to not be assessed and had the potential for respiratory depression (breathing disorder characterized by slow and ineffective breathing) and/or other deterioration of the patient's condition to go undetected.

Findings:

1. During a review of Patient (Pt) 1's "History and Physical" (H&P), dated 9/17/21, the H&P indicated, " ... CHIEF COMPLAINT: Hematuria (the presence of blood in a person's urine) blocked catheter (tube that is inserted into the bladder) ...HISTORY OF PRESENT ILLNESS ...85 years old male came to the emergency room complaining of blocked Foley catheter (flexible tube placed in the bladder to drain urine ) ... Patient had TURP (transurethral resection of the prostate- surgery to remove parts of the prostate gland [walnut-sized gland located between the bladder and the penis] through the penis) done by patient urologist (physician diagnoses and treats diseases of the urinary tract system) and patient has indwelling (placed or implanted within the body) Foley catheter ... Foley catheter was not draining and draining blood clots so he comes to the emergency room ... Patient being hospitalized for further evaluation continuous bladder irrigation (procedure to open a plugged catheter) and follow-up urology consultation ... Vital Signs (measurements taken to help assess the general physical health of a person, give clues to possible diseases, and show progress toward recovery): Temperature: 37.1 (09/16 23:48 [11:48 p.m.]) ... Pulse: 110 (pulse for healthy adults ranges from 60 to 100 beats per minute) (09/16 23:48 [11:48 p.m.]) ... Respiration: 18 (09/16 23:48 [11:48 p.m.) ... BP (blood pressure- amount of blood your heart pumps and the amount of resistance to blood flow in your arteries) : 184/90 (normal blood pressure for most adults is defined as a systolic pressure of less than 120 and a diastolic pressure [top number] of less than 80 [bottom number]) (09/16 23:48 [11:48 p.m.]) ... Pulse Ox (oximetry- measuring of the percentage of oxygen-saturated hemoglobin in the blood): 98 (09/16 23:48 [11:48 p.m.]) ... Pain Score: 10 (pain scale is a numerical scale from 0 to 10. 0 means no pain; one to three means mild pain; four to seven is considered moderate pain; eight and above is severe pain) (09/16 23:50 [11:50 p.m.]) ... "

During a concurrent interview and record review at 11/24/21, at 1:35 p.m., with the Emergency Department Manager (EDM), Pt 1's electronic clinical records dated 9/16/21 through 9/17/21 were reviewed. The EDM stated she was familiar with Pt 1's ED encounter and validated Pt 1's physician's orders indicated:

" ...HYDROmorphone ([brand name] Inj [injection]) (HYDROmorphone 0.5 mg (milligrams- units of measurement) / (per) 0.5 ml (milliliter- units of measurement) INJ 0.5 ml ([brand name] GEq [generic equivalent]) 0.5mg, IV (intravenous- into the skin) Push, Inject, Q3h (every 3 hours), Routine, PRN (as needed), Pain- Moderate...09/17/21 0:38:00 PDT (pacific daylight time) ...

HYDROmorphone ([brand name] Inj) (HYDROmorphone 0.5 mg/0.5 ml INJ 0.5 ml ([brand name] GEq) 0.5 mg, IV Push, Inject, Q3h, Routine, PRN, Pain· Moderate, 09/17/21 5:44:00 PDT ...

HYDROmorphone ([brand name] Inj) (HYDROmorphone 1 mg/ml INJ 1 ml ([brand name] GEq) 1 mg, IV Push, Inject, Q3h, Routine, PRN, Pain· Severe, 09/17/21 5:44:00 PDT ..."

The EDM validated between 9/16/21 at 11:51 p.m. through 9/17/21 at 8:31 a.m., Pt 1's pain medications were not administered as ordered by the physician. The EDM stated pain medications should have been administered as ordered to manage or address the pain of patients or to minimize the pain patients were experiencing to provide a level of comfort.

During a concurrent interview and record review at 11/29/21 at 11:25 a.m., with Registered Nurse (RN) 4, Pt 1's electronic clinical records were reviewed. RN 4 stated he cared for Pt 1 and validated on admission (9/17/21), Pt 1's pain score was 10/10 (severe pain). RN 4 reviewed Pt 1's electronic clinical records and validated Pt 1's physician orders indicated:

" ... HYDROmorphone ([brand name] Inj) (HYDROmorphone 0.5 mg/0.5 ml INJ 0.5 ml ([brand name] GEq) 0.5mg, IV Push, Inject, Q3h, Routine, PRN, Pain- Moderate ...09/17/21 0:38:00 PDT ...

HYDROmorphone ([brand name] Inj) (HYDROmorphone 0.5 mg/0.5 ml INJ 0.5 ml ([brand name] GEq) 0.5 mg, IV Push, Inject, Q3h, Routine, PRN, Pain· Moderate, 09/17/21 5:44:00 PDT ...

HYDROmorphone ([brand name] Inj) (HYDROmorphone 1 mg/ml INJ 1 ml ([brand name] GEq) 1 mg, IV Push, Inject, Q3h, Routine, PRN, Pain· Severe, 09/17/21 5:44:00 PDT ..."

RN 4 validated Pt 1's pain medications were not administered to Pt 1 from admission to when Pt 1 left the hospital (9/16/21 at 11:50 p.m. to 9/17/21 at 8:31 a.m., a total of eight hours and 41 minutes). RN 4 stated RNs should administer pain medication as ordered to relieve patients' pain or to manage patients' pain to keep patient comfortable.

During an interview on 11/22/21, at 8:38 a.m., with Pt 1, Pt 1 stated he went to [Hospital A] on 9/16/21 and was seen in ED. Pt 1 stated he waited several hours, no one helped him address the awful pain he experienced. Pt 1 stated he screamed in pain, but ED staff did not give him any pain medication while he was in the ED. Pt 1 stated he during his entire stay while in the ED, did not receive any pain medication.

During a review of the facility's P&P titled, "MEDICATION POLICIES," dated July 2019, the P&P indicated, " ... PURPOSE: To establish guidelines for the administration and documentation of medications ... OUTCOME: ...Patients will receive medications according to the physician orders ..."

During a review of the facility's P&P titled, "PAIN MANAGEMENT GUIDELINES," dated November 2020, the P&P indicated, " ...PURPOSE: To provide guidelines for effective pain management including assessment and education to achieve pain relief with minimal risks and safe outcomes ...OUTCOME: Patients are timely assessed/re-assessed for pain, educated on their treatment, and managed appropriately for complications ... DEFINITIONS ...Pain is a complex, subjective response with multiple qualitative (measured by quality) and quantifiable (measured as a quantity) features, including intensity, time, course, quality, impact and personal meaning ... Pain management: an interdisciplinary (involving two or more disciplines), therapeutic approach to pain control using a combination of pharmacologic, cognitive-behavioral, psychological and physical treatments ...POLICY ...The Registered Nurse (RN) will evaluate for pain ...The RN will administer analgesia (pain relief) as ordered for the patient's assessment and pain level score..."

2. During a review of Pt 5's "History and Physical", dated 11/1/21, the H&P indicated, " ... Chief Complaint: Dysuria (discomfort, pain, or burning when urinating) x (for) 5 days ... History of Present Illness: 58 year old Spanish speaking male with past medical history of BPH (prostate gland enlargement- a common condition as men get older. An enlarged prostate gland can cause uncomfortable urinary symptoms, such as blocking the flow of urine out of the bladder) and bladder calculi (stone that is a concretion of material), mass presented with dysuria x 5 days. Symptoms have been progressively worsening. Associated with non radiating lower abdominal pain 5/10 (five out of ten) in intensity, hematuria, and increased frequency in urination. Patient states that his symptoms were manageable until yesterday when he was returning from his one day trip to Mexico. Patient was on the airplane when he started experiencing difficulty in urination and started passing blood. After that he was not able to urinate at all. Associated with fever and chills. He was given [brand name of acetaminophen (pain and fever reliever medication)] and tramadol (pain reliever to treat moderate to moderately serve pain), which resulted in slight relief of symptoms. Denies nausea, vomiting, or urinary incontinence (the loss of bladder control) ...Vitals Signs ...Pain Score 5 [out of 10] (11/01 10:58 [a.m.]"

During a concurrent interview and record review on 12/1/21, at 10:35 a.m., with the Risk Management Coordinator (RMC), Pt 5's electronic clinical records and the facility's P&P titled, "Medication Policies" were reviewed. The RMC stated she was familiar with Pt 5's ED encounter and validated Pt 5's medication administration record (MAR) dated 11/1/21 indicated, " ... acetaminophen-HYDROcodone ([brand name] 5 mg ... 1 Tab (tablet), PO (by mouth), Tab, Q6h (every six hours), Routine, PRN Pain- Moderate ...11/01/21 17:34 [5:34 p.m.] (date and time medication was ordered) ... Medication [was administered] 11/1/21 21:32 [9:32 p.m.] (3 hours and 58 minutes late) ...Acetaminophen-hydrocodone (combination medication is used to relieve moderate to severe pain) ... 1 tab ... pain score 5 (out of 10) ..." The RMC stated Pt 5's pain medication was administered approximately three and a half (3.5) hours after from the time the medication was ordered. The RMC stated the facility's P&P titled, "Medication Policies" should be followed, and pain medications should be administered by the RNs within 60 minutes before or 60 minutes after the scheduled time for patients to receive their medications according to the physician's order, to address patients' pain in a timely manner.

During a review of Pt 6's "ED Physician Notes", dated 11/1/21, the ED Physician Notes indicated, " ...Time seen: Date & time 11/01/2021 11:14 [a.m] ... History of Present Illness 53 y/o (year old) Hmong- speaking male presents to the ED c/o (complain of) generalized 9/10 penile pain x3 days. Pt states the pain exacerbates (feels worse) when urinating and radiates (spreads) from his penis to scrotum (in the male reproductive system) and rectum and finally to lower back ... Denies any hematochezia (blood in stool), hematuria, ... Pt notes the pain is most remarkable while laying down. He has taken 800 mg ibuprofen (drug used to treat fever, swelling, pain, and redness by preventing the body from pt making a substance that causes inflammation) to momentary relief of sx (symptoms) ..."

During a concurrent interview and record review on 12/1/21 at 2:03 p.m., with RN 10, Pt 6's electronic clinical records were reviewed. RN 10 stated she was familiar with Pt 6's ED encounter and validated Pt 6's MAR indicated, " ... acetaminophen-HYDROcodone [brand name] 5 mg ... 1 Tab, PO, Tab, Once STAT (immediately), 11/01/21 11:34 [a.m.] (date and time medication was ordered) ... Medication [administered at] 11/1/21 14:02 [2:02 p.m.] (2 hours and 28 minutes late) ...Acetaminophen-hydrocodone ... 1 tab ..." RN 10 validated Pt 6's pain medication was administered approximately two and a half (2.5) hours after from the time it was ordered by the physician. RN 10 stated she should have administered Pt 6's pain medication immediately when it was ordered to manage Pt 6's pain and to ensure the patient's comfort.

During a review of Pt 7's "ED Physician Notes", dated 11/2/21, the ED Physician Notes indicated, " ...Time seen: Date & time 11/02/2021 02:23 [a.m.] ... History of Present Illness 65-year-old Spanish and English speaking male presents complaining of severe difficulty urinating. He can only urinate some drops. He underwent bilateral (both sides) inguinal (groin) herniorrhaphy (type of hernia repair surgery where a mesh patch is sewn over the weakened region of tissue) yesterday, 11/1/2021 ... Vital Signs ... 11/2/2021 02:24 [a.m.] ... Temperature ... 36.7 Degrees C (Celsius- a unit of temperature on the Celsius scale) ... Pulse rate 71 BPM (beats per minute) ... Respiratory Rate 18 Br PM (breaths per minute) ... Pulse Oximetry 95%... Systolic BP 130 mmHg (millimeters of mercury- unit of measurement) ... Diastolic BP 60 mmHg ... Pain score 10 (out of 10) ..."

During a concurrent interview and record review on 12/1/21 at 2:55 p.m., with RN 1, Pt 7's electronic clinical records were reviewed. RN 1 stated he was familiar with Pt 7's ED encounter and validated Pt 7's MAR dated 11/2/21 indicated, " ... morphine (Morphine Inj) (Morphine 4 mg/ ... 4 mg, IV Push, InJect. Once, STAT immediately, 11/02/21 2:33 [a.m.] (date and time ordered) ..., Medication [administered at] 11/2/2021 5:20 [a.m.] (2 hours and 47 minutes late) morphine 4 mg ..." RN 1 stated Pt 7's pain medication was administered approximately two and a half (2.5) hours after the time it was ordered. RN 1 stated RNs should have administered the pain medication immediately after it was ordered to manage Pt 7's pain and to ensure patient's comfort.

During a concurrent interview and record review on 12/3/21 at 8:39 a.m., with the RMC, Pt 5, 6, and 7's electronic clinical records were reviewed. The RMC stated she reviewed Pt 5, Pt 6 and Pt 7's clinical records and validated the RNs did not administer pain medication within 60 minutes before or 60 minutes after the scheduled time of the medications. The RMC reviewed the facility's P&P titled, "Medication Policies" and stated the P&P should have been followed and pain medications should be administered by the RNs within 60 minutes before or 60 minutes after the scheduled time to received medications according to physicians' order and to address patients' pain in a timely manner.

During a review of the facility's P&P titled, "MEDICATION POLICIES," dated July 2019, the P&P indicated, " ... PURPOSE: To establish guidelines for the administration and documentation of medications ... OUTCOME: ...Patients will receive medications according to the physician orders ...All medications administered to the patient will be documented on the EMAR (electronic medication administration record) ... ADMINISTRATION OF MEDICATIONS ... Medications administered outside the administration windows will require documentation ... Medications specified by the physician ... Non-Time Critical medications ... above and may be administered up to 60 minutes before or 60 minutes after the scheduled time ... PROCEDURE ...The nurse is responsible for checking that the right medication is given to the right patient, in the right dose, by the right route and at the right time ..."

3. During a review of Pt 2's "History and Physical", dated 11/23/21, the H&P indicated, " ...Time seen: Date & time 11/23/2021 19:28 (7:28 p.m.) ... History of Present Illness ... HPI (History of Present Illness): 36 Spanish-speaking female presents with left flank (side between the ribs and hip) pain onset yesterday. She has been taking ibuprofen which would work for about 10 minutes and then her pain would return. Denies fever, nausea, vomiting, diarrhea, or dysuria. Denies blood in her urine ... ROS (Review of Systems): (+) [positive] Left flank pain ..."

During a concurrent interview and record review on 11/24/21, at 10:20 a.m., with the Emergency Department Interim Director (EDID), Pt 2's electronic clinical records were reviewed. The EDID stated she was familiar with Pt 2's ED encounter and validated the RN did not reassess Pt 2's pain after pain medication was administered. The EDID stated pain should be reassessed after pain medication was administered by the RNs to monitor if the pain medication administered was effective and if patients needed additional intervention to address their pain.

During a concurrent interview and record review at 12/1/21 at 10:30 a.m., with the EDID, Pt 2's electronic clinical records and the facility's P&P titled, "Pain Management Guidelines" were reviewed. The EDID stated she was familiar with Pt 2's ED encounter and validated Pt 2's MAR dated 11/23/21 indicated " ...Ketorolac (anti-inflammatory to treat pain) ([brand name] Inj) (Ketorolac 30 mg/mL Vial (a small container) 1 mL ([brand name] GEq) 30 mg IM (intramuscular- into the muscle tissue), Inject [administered] on 11/23/2021 20:51 [8:51 p.m.] ... Pain score 10 (out of 10)" The EDID validated there was no reassessment of pain completed after Pt 2's pain medication was administered. The EDID stated reassessment of pain should be completed by the RN after pain medication was administered. The EDID reviewed the facility's P&P titled, "Pain Management Guidelines" and stated the P&P should have been be followed.

During a review of Pt 5's "History and Physical", dated 11/1/21, the H&P indicated, " ... CHIEF COMPLAINT: Dysuria x 5 days ... HISTORY OF PRESENT ILLNESS: 58 year old Spanish speaking male with past medical history of BPH and bladder calculi, mass presented with dysuria x 5 days. Symptoms have been progressively worsening. Associated with non radiating lower abdominal pain 5/10 in intensity, hematuria, and increased frequency in urination. Patient states that his symptoms were manageable until yesterday when he was returning from his one day trip to Mexico. Patient was on the airplane when he started experiencing difficulty in urination and started passing blood. After that he was not able to urinate at all. Associated with fever and chills. He was given [brand name of acetaminophen (pain and fever reliever medication)] and tramadol, which resulted in slight relief of symptoms. Denies nausea, vomiting, or urinary incontinence ..."

During a concurrent interview and record review on 12/1/21, at 10:35 a.m., with the RMC, Pt 5's electronic clinical records were reviewed. The RMC stated she was familiar with Pt 5's ED encounter and validated Pt 5 MAR dated 11/1/21 indicated, " ... acetaminophen-HYDROcodone [brand name] 5 mg ... 1 Tab, PO, Tab, Q6h, Routine, PRN Pain- Moderate ... 11/01/21 17:34 [5:34 p.m.] (date and time medication was ordered) ... Medication [administered at] 11/1/21 21:32 [9:32 p.m.] Acetaminophen-hydrocodone ... 1 tab ... pain score 5 (out of 10) ...Pain/PRN response [blank-not completed]. The RMC validated Pt 5's pain re assessment was not completed after the pain medication was administered. The RMC reviewed the facility's P&P titled, "Pain Management Guidelines" and stated the P&P should have been followed.

During a review of Pt 6's "ED Physician Notes", dated 11/1/21, the ED Physician Notes indicated, " ...Time seen: Date & time 11/01/2021 11:14 [a.m] ... History of Present Illness 53 y/o Hmong- speaking male presents to the ED c/o generalized 9/10 penile pain x3 days. Pt states the pain exacerbates when urinating and radiates from his penis to scrotum and rectum and finally to lower back ... Denies any hematochezia, hematuria, ... Pt notes the pain is most remarkable while laying down. He has taken 800 mg ibuprofen to momentary relief of sx ..."

During a concurrent interview and record review at 12/1/21 at 2:03 p.m., with RN 10, Pt 6's electronic clinical records were reviewed. RN 10 stated she was familiar with Pt 6's ED encounter and validated Pt 6's MAR dated 11/1/21, indicated, " ... acetaminophen-HYDROcodone [brand name] 5 mg ... 1 Tab, PO, Tab, Once STAT, 11/01/21 11:34 [a.m.] (date and time medication was ordered) ... Medication [administered at] 11/1/21 14:02 [2:02 p.m.] Acetaminophen-hydrocodone ... 1 tab ... pain score 10 ...Pain/PRN response [blank-not completed]. RN 10 stated Pt 6's pain re assessment was not completed after the pain medication was administered. RN 10 stated she should have reassessed Pt 6's pain after she administered Pt 6's pain medication to identify if the pain medication was effective or Pt 6's pain was an acceptable level.

During a review of Pt 7's "ED Physician Notes", dated 11/2/21, the ED Physician Notes indicated, " ...Time seen: Date & time 11/02/2021 02:23 [a.m.] ... History of Present Illness 65-year-old Spanish and English speaking male presents complaining of severe difficulty urinating. He can only urinate some drops. He underwent bilateral inguinal herniorrhaphy yesterday, 11/1/2021 ... Vital Signs ... 11/2/2021 02:24 [a.m.] ... Temperature ... 36.7 Degrees C ... Pulse rate 71 BPM ...Respiratory Rate 18 Br PM ...Pulse Oximetry 95%... Systolic BP130 mmHg ... Diastolic BP 60 mmHg ... Pain score 10 ..."

During a concurrent interview and record review on 12/1/21, at 2:55 p.m., with RN 1, Pt 7's electronic clinical records were reviewed. RN 1 stated he was familiar with Pt 7's ED encounter and validated Pt 7's MAR dated 11/2/21, indicated, " ... morphine (Morphine Inj) (Morphine 4 mg/ ... 4 mg, IV Push, InJect. Once, STAT, 11/02/21 2:33 [a.m.] (date and time medication was ordered) ..., Medication [administered at] 11/2/2021 5:20 [a.m.] morphine 4 mg ...pain score 5 (out of 10) ..." RN 1 stated Pt 7's pain reassessment was not completed after pain medication was administered. RN 1 stated he should have reassessed Pt 7's pain after the administration of pain medication to identify if the pain medication was effective or if Pt 7's pain was an acceptable level.

During a concurrent interview and record review on 12/3/21, at 8:39 a.m., with the RMC, Pts 5, 6, and 7's electronic clinical records were reviewed. The RMC stated she reviewed the charts and validated Pts 5, 6, Pt 7's did not have a pain reassessment after their pain was administered. The RMC stated pain should be reassessed after pain medication was administered to monitor if the patients' pain medication administered was effective and if patients needed additional intervention to address their pain.

During a review of the facility's P&P titled, "PAIN MANAGEMENT GUIDELINES," dated November 2020, the P&P indicated, " ...PURPOSE: To provide guidelines for effective pain management including assessment and education to achieve pain relief with minimal risks and safe outcomes ...OUTCOME: Patients are timely assessed/re-assessed for pain ...DEFINITIONS ...Pain is a complex, subjective response with multiple qualitative and quantifiable features, including intensity, time, course, quality, impact and personal meaning ...POLICY ...The Registered Nurse (RN) will evaluate for pain and teach the patient to score their pain and/or relief according to an appropriate/designated pain scale ...The RN will administer analgesia as ordered for the patient's assessment and pain level score... Reassessment criteria will be used to evaluate and respond to the patient's pain ... Documented reassessment will include pain and sedation levels ... Pain will be reassessed and documented 15 minutes after IV pain medicine administration and 1 hour after oral pain medicine administration ... PROCEDURE ...Assess and reassess pain at regular intervals appropriate for the specific patient including ...Following pain management interventions ...Elements of pain assessment ... Presence of Pain, Pain scale score and Scale type used ..."

4. During a review of Pt 3's "ED Physician Notes", dated 11/22/21, the ED Physician Notes indicated, " ...Time seen: Date & time 11/22/2021 21:34 [9:34 p.m.] ... History of Present Illness ...Brief History: 58 y/o male presents to the ED with left sided rib pain s/p (status post) fall on 11/20/2021. Pt states his right knee had given out which caused him to fall ... When he fell, the pt mentions he hit the corner of a 'marble counter'. His pain has been getting worse since his fall. Additionally, the pt mentions having some SOB (shortness of breath) secondary to his pain and bruising to his right abdomen. Denies fever, chill ... ROS: SOB, Rib pain, Fall, Right knee pain ... Vital signs 11/22/2021 21:30 [9:30 p.m.] ... Temperature ... 36.7 Degrees C ...Pulse rate 75 BPM ...Respiratory Rate 17 Br PM ... Pulse Oximetry 95%... Systolic BP 185 mmHg ...Diastolic BP 106 mmHg ..."

During a concurrent interview and record review at 12/1/21 at 10:45 a.m., with the EDID, Pt 3's electronic clinical records were reviewed. The EDID stated she was familiar with Pt 3's ED encounter and validated Pt 3's MAR dated 11/23/21, indicated:

" ... Morphine 4 mg/mL INJ 1 mL [administered at] 11/23/21 00:06 [12:06 a.m.] Respiratory rate [blank- not completed] ...

HYDROmorphone 1 mg/mL INJ 1 mL [administered at] 11/23/21 1:22 [p.m.] Respiratory rate [blank- not completed] ...

HYDROmorphone 1 mg/mL INJ 1 mL [administered at] 11/23/21 3:49 [p.m.] Respiratory rate [blank- not completed] ..."

The EDID stated RNs did not complete three respiratory rate assessments following administration of a narcotic medication.

During a concurrent interview and record review at 11/24/21, at 10:20 a.m., with the EDID, Pt 3's electronic clinical records were reviewed. The EDID stated she was familiar with Pt 3's ED encounter and validated Pt 3's respiratory rate in the clinical record, dated 11/23/21 indicated " ... [blank- on spreadsheet] ..." The EDID stated RNs did not monitor Pt 3's quality and adequacy of respiration following administration of narcotic. The EDID stated the quality and adequacy of patients' respiration should be monitored by the RNs following administration of narcotic medication to identify oversedation (excessive medication that affects consciousness of an individual) or respiratory depression for patient safety.

During a review of the facility's P&P titled, "PAIN MANAGEMENT GUIDELINES," dated November 2020, the P&P indicated, " ...PURPOSE: To provide guidelines for effective pain management including assessment and education to achieve pain relief with minimal risks and safe outcomes ...OUTCOME: Patients are timely assessed/re-assessed for pain, educated on their treatment, and managed appropriately for complications ... POLICY ...The Registered Nurse (RN) will evaluate for pain and teach the patient to score their pain and/or relief according to an appropriate/designated pain scale ...The RN will administer analgesia as ordered for the patient's assessment and pain level score... Reassessment criteria will be used to evaluate and respond to the patient's pain ... Documented reassessment will include pain and sedation levels ... Pain will be reassessed and documented 15 minutes after IV pain medicine administration and 1 hour after oral pain medicine administration ... PROCEDURE ... Following administration of narcotic medication, monitor the patient for quality and adequacy of respiration and the depth of sedation. Report signs of over-sedation, respiratory depression or any other adverse reaction to the physician immediately ..."