HospitalInspections.org

Based on interviews, medical record review and facility document review, it was determined the facility failed to assess and then reassess a patient's pain level and vitals in accordance with facility policy and procedure for one (1) out of three (3) patient's medical records reviewed (Patient #2).

Findings:

A review of the medical record for Patient #2 on October 29, 2024, revealed Patient #2 presented to the ED on September 27, 2024, at 7:55 PM with a chief complaint of left knee and right hip pain while experiencing a sickle cell crisis. The Patient was triaged at 8:13 PM as an ESI three (3). Vital signs were documented but there was no documentation of an initial pain assessment. The patient was returned to the ED waiting room and was not roomed until 11:27 PM. There is no documentation that Patient #2 was ever reassessed while in the waiting room or at the time the patient was placed in an ED room. Patient #2's first pain assessment was documented on September 28, 2024, at 1:16 AM, over five (5) hours after the patient was triaged. The patient's pain was assessed as "severe" and the patient was administered Tylenol (pain reliever) at 1:16 AM and Toradol (nonsteroidal anti-inflammatory drug used to treat moderate to severe pain - drugs.com) at 1:18 AM for the pain.

During an interview on October 29, 2024, at 1:57 PM, Staff Member #6 indicated that it is the expectation of the triage nurse to reassess a patient identified as an ESI 3 every two (2) hours for vitals and pain while in the ED waiting room. If the patient receives pain medication once in a room, the patient's pain should be reassessed every hour.

During an interview on October 29, 2024, at 2:12 PM, Staff Member #10 indicated that it is the expectation that patients waiting in the ED waiting room be reassessed for vitals and pain every two (2) hours, if the patient has been assigned a ESI level of three (3). Staff Member #10 indicated that any patient that presents to the ED should initially be assessed on a pain scale of one (1) to ten (10) or "mild to severe". Once a patient is roomed, the pain should be reassessed at that time. The Staff Member further indicated that once given pain medications, the patients should be reassessed for pain every thirty (30) to sixty (60) minutes.

A review of the facility's policy, "Emergency Care and Treatment," with a revision date of January, 2019, reads, in part:
..."Triage
... 2. Triage Assessment:
... b. ... The triage assessment and patient Emergency Severity Index (ESI) are assigned by an RN.
... c. The triage assessment consists of:
1. A focused history and assessment of the presenting complaint;
2. Pertinent psychosocial, surgical, and medical history....
... e. Once the triage assessment is competed, the nurse assigns an ESI level.... The ESI level determines the priority of care....
... f. Patients who remain in the waiting area or triage area after initial assessment and prior to admission to a treatment area are re-evaluated consistent with the ESI level assigned to the patient. Patients are re-evaluated by a nurse, paramedic, or EMT [emergency medical technician]. The guidelines for completion of re-evaluation are within the following time frames.
... 3. ESI Level 3: Every 2 hours....
The nurse, paramedic or EMT will record the patient's vital signs and interview the patient to determine if there is a change in the patient's clinical condition. The interview consists of ascertaining if the patient reports feeling, [sic] better, worse or the same and alerts the provider. If the vital signs are determined to be outside of the normal range or if there is a change in the patient's clinical condition, the nurse, paramedic, or EMT will notify the triage nurse....
... 3. Triage ESI Levels: Definitions:
a. Patients are triaged according to 5 levels:
... 3. ESI LEVEL 3 (NON-URGENT): Any illness or injury which can be delayed 4 to 6 hours before medical intervention, without deterioration in the patient's condition.
... Placement in an Emergency Treatment Room
... Assessment in the Treatment Area
1. ED admission assessment:
a. All patients are assessed by a registered nurse and physician upon arrival to the ED from the Triage Area....
b. Nursing assessments are focused on the patient's presenting complaint....
... d. Nursing assessments are documented in the medical record....

A review of the facility's policy, "Pain Management," with a revision date of August, 2022, reads, in part:
... Pain Screening and Assessment
1. All patients will be screened for the presence of pain or history of persistent pain during emergency department visit, upon initial admission, after any known pain-producing event, and at unit standard intervals....
2. If the pain screening indicates the presence of pain, a comprehensive pain assessment will be completed to evaluate the level of pain including the origin/cause, location, duration, intensity, aggravating factors, alleviating factors, effects of pain, and whether current pain regime is effective....
3. The pain assessment is based on patient self-report and/or behavioral observation tools appropriate for the patient's age, condition and/or identified needs. The pain assessment tools available are used to categorize pain levels as Mild, Moderate, Severe:
... g. Numerical Rating Scale, 0-10 with faces.
... Pain Reassessment
1. Reassessment to evaluate the patient's response to a PRN [as needed] pain-relieving intervention will be completed within 60 minutes after medication administration.... Reassessment includes monitoring progress toward pain management goal....
... 3. Documentation will include the pain intensity assessment and response to pain intervention.