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Based on interview and record review, the facility failed to ensure the facility's policies and procedures were implemented for five of 20 sampled patients (Patients 11, 12, 14, 17, and 19) when:

1. For Patients 11, and 12, critical laboratory results were not reported to the provider;

2. For Patient 11, an initial pain assessment was not performed;

3. For Patient 12, pain assessment documentation was incomplete;

4. For Patient 14, a pain reassessment after treatment was not performed; and

5. For Patients 17, and 19, pain medication was not provided in a timely manner after reporting pain.

These failures had the potential to compromise patient safety and result in inadequate pain management.

Findings:

1.a. On July 14, 2025, at 2:30 p.m., a review of Patient 11's record was conducted with the Regulatory Compliance Nurse (RC) 2.

A facility document titled, "History and Physical [H&P]," dated July 11, 2025, was reviewed. The document indicated Patient 11 was admitted to the facility on July 11, 2025, for altered mental status (AMS, a significant change in a person's cognition, attention, mood, and/or behavior) and hypernatremia (high salt levels in the blood).

A facility document titled, "Result Details," dated July 12, 2025, at 8:32 a.m., was reviewed. The document indicated Patient 11 had a sodium (Na) level of 179 mmol/L (millimoles per liter, a unit of measurement) and further indicated a reference range (a set of values that indicates what is considered normal for a specific laboratory test result in a healthy population) of 136 to 145 mmol/L. There was no documented evidence the Na level of 179 mmol/L was reported to the physician.

A facility document titled, "Result Details," dated July 13, 2025, at 12:48 a.m., was reviewed. The document indicated Patient 11 had a Na level of 180 mmol/L. There was no documented evidence the Na level of 180 mmol/L was reported to the physician.

A facility document titled, "Result Details," dated July 13, 2025, at 4:27 a.m., was reviewed. The document indicated Patient 11 had a Na level of 180 mmol/L. There was no documented evidence the Na level of 180 mmol/L was reported to the physician.

On July 14, 2025, at 4 p.m., an interview was conducted with the Intensive Care Unit Director (ICD). The ICD stated she would anticipate that nursing would call the physician to report the critical laboratory values.

On July 16, 2025, at 11:53 a.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated she would expect the policy to be followed, and for nursing staff to report critical laboratory values to the physician within one hour of receiving the result and to document the report.

The facility policy and procedure (P&P) titled, "Critical Values Reporting," dated July 20, 2023, was reviewed. The P&P indicated, "...All critical values for inpatients must be reported within one hour or less to the ordering physician...who will act upon the information...The Registered Nurse (RN) receiving the CVR [critical value report] will document the physician notified, the critical value, the read back and verify, the date and time...using...The Critical Value Reporting form within the Electronic Medical Record (EMR): Flowsheet, Provider Interaction Tab...Critical Limits...Na (Sodium)...LOW...[less than or equal to] 120 mmol/L...HIGH...[greater than or equal to] 160 mmol/L..."

1.b. On July 15, 2025, at 9:03 a.m., a review of Patient 12's record was conducted with RC 2.

A facility document titled, "H&P," dated July 6, 2025, was reviewed. The document indicated Patient 12 was admitted to the facility on July 6, 2025, with a diagnosis of cardiogenic shock (a life-threatening condition where the heart is unable to pump enough blood to meet the body's needs).

A facility document titled, "Result Details," dated July 6, 2025, at 5:10 p.m., was reviewed. The document indicated Patient 12 had positive blood cultures (a result that indicates bacteria or other microorganisms have been detected in a blood sample). There was no documented evidence the positive blood cultures were reported to the physician.

On July 16, 2025, at 11:51 a.m., an interview was conducted with the Chief Clinical Integration Officer (CIO). The CIO stated nursing did not document that the physician was notified.

On July 16, 2025, at 11:53 a.m., an interview was conducted with the Chief Nursing Officer (CNO). The CNO stated she would expect the policy to be followed, and for nursing staff to report critical laboratory values to the physician within one hour of receiving the result and to document the report.

The facility policy and procedure (P&P) titled, "Critical Values Reporting," dated July 20, 2023, was reviewed. The P&P indicated, "...All critical values for inpatients must be reported within one hour or less to the ordering physician...who will act upon the information...The Registered Nurse (RN) receiving the CVR [critical value report] will document the physician notified, the critical value, the read back and verify, the date and time...using...The Critical Value Reporting form within the Electronic Medical Record (EMR): Flowsheet, Provider Interaction Tab...Critical Limits...Blood Culture...Positive..."

2. On July 14, 2025, at 2:30 p.m., a review of Patient 11's record was conducted with Regulatory Compliance Nurse (RC) 2.

A facility document titled, "History and Physical [H&P]," dated July 11, 2025, was reviewed. The document indicated Patient 11 was admitted to the facility on July 11, 2025, for altered mental status (AMS, a significant change in a person's cognition, attention, mood, and/or behavior) and hypernatremia (high salt levels in the blood).

A facility document titled, "Event Log," was reviewed. The document indicated Patient 11 arrived the Emergency Department (ED) on July 11, 2025, at 7:56 p.m.

A facility document titled, "Flowsheets...Vital Signs...Pain Assessment," dated July 11, 2025, through July 12, 2025, was reviewed. The document indicated Patient 11 did not have a documented pain assessment from the time of arrival to the facility until July 12, 2025, at 10 p.m.

On July 16, 2025, at 11:53 a.m., an interview was conducted with the CNO. The CNO stated an assessment of patients' pain should be performed.

The facility policy and procedure (P&P) titled, "Pain Assessment & Management," dated March 15, 2025, was reviewed. The policy indicated, "...The...nurse...shall assess the presence of pain on all patients upon initial evaluation, or assessment and at an ongoing basis..."

3. On July 15, 2025, at 9:03 a.m., a review of Patient 12's medical record was conducted with RC 2.

A facility document titled, "H&P," dated July 6, 2025, was reviewed. The document indicated Patient 12 was admitted to the facility on July 6, 2025, with a diagnosis of cardiogenic shock (a life-threatening condition where the heart is unable to pump enough blood to meet the body's needs).

A facility document titled, "Flowsheets...Vital Signs...Pain Assessment," dated July 7, 2025, was reviewed. The document indicated Patient 12 had a pain level of 3 (three, on a numeric pain assessment tool of zero to ten with zero indicating no pain and ten indicated the worst pain) at 9 a.m., five at 9:32 a.m., four at 10 a.m., three at 10:32 a.m., two at 12 p.m., six at 1 p.m., four at 5:27 p.m., and two at 6 p.m. There was no documented evidence of the pain goal, pain type, pain location, pain orientation, pain description, pain onset, or pain intervention(s).

On July 15, 2025, at 11:15 a.m., RC 2 stated the pain documentation for Patient 12 was incomplete.

The facility policy and procedure (P&P) titled, "Pain Assessment & Management," dated March 15, 2025, was reviewed. The policy indicated, "...Pain assessment: information from the patient about provoking factors, quality/characteristics, region/radiation, relieving factors, associated symptoms, timing, and pain scores obtained with a pain assessment tool ...The...nurse...shall assess the presence of pain on all patients upon initial evaluation, or assessment and at an ongoing basis..."

4. On July 15, 2025, at 1:18 p.m., a review of Patient 14's record was conducted with RC 2.

A facility document titled, "H&P," dated July 13, 2025, was reviewed. The document indicated Patient 14 was admitted to the facility on July 13, 2025, with a diagnosis of schizoaffective disorder (a mental health condition that is a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania) and danger to self.

A facility document titled, "Flowsheets...Vital Signs...Pain Assessment," dated July 13, 2025, at 5:43 p.m., was reviewed. The document indicated Patient 14 had acute abdominal pain with a pain level of five on the numeric pain assessment tool.

A facility document titled, "Medication," dated July 13, 2025, was reviewed. The document indicated on July 13, 2025, at 6:09 p.m., Patient 14 was administered, "...gi cocktail [a mixture of medications used for stomach discomfort] oral suspension 15 ml [milliliter, unit of measurement]..."

There was no documented evidence Patient 14's abdominal pain was reassessed to evaluate the effectiveness of the medication.

On July 16, 2025, at 11:53 a.m., an interview was conducted with the CNO. The CNO stated reassessment of patients' pain should be performed.

The facility policy and procedure (P&P) titled, "Pain Assessment & Management," dated March 15, 2025, was reviewed. The policy indicated, "...Reassessments after intervention to lessen pain should take place within a clinically appropriate time frame...to evaluate the effectiveness of pain management interventions..."

5.a. On July 15, 2025, at 3 p.m., a review of Patient 17's record was conducted with RC 2.

A facility document titled, "ED [emergency department] Provider Notes," dated May 23, 2025, was reviewed. The document indicated Patient 17 presented to the ED, "...with concern for foreign body [an object that enters the body and becomes stick in a place it shouldn't be]..."

A facility document titled, "Flowsheets...Vital Signs...Pain Assessment," dated May 23, 2025, was reviewed. The document indicated Patient 17 had abdominal pain with a pain level of five on the numeric pain assessment tool at 4:52 p.m. The document further indicated Patient 17 had abdominal pain with a pain level of five at 7:24 p.m. There was no documented evidence Patient 17 received treatment for the reported abdominal pain from 4:52 p.m. to 7:24 p.m.

A facility document titled, "Progress Notes" dated May 23, 2025, at 7:09 p.m. was reviewed. The document indicated, "Discussed risks and benefits of attempting removal of IUD [intrauterine device, a small device placed into the uterus to prevent pregnancy]...IUD hook was inserted into the cervix [the lower narrow end of the uterus]..." There was no documented evidence Patient 17 was medicated for anticipatory pain prior to the procedure.

On July 16, 2025, at 11:53 a.m., an interview was conducted with the CNO. The CNO stated a patient presenting to the ED with complaints of pain should have the pain treated as soon as possible, but not more than one hour after a positive pain assessment. The CNO stated Patient 17 should have been medicated for pain prior to the procedure.

The facility policy and procedure (P&P) titled, "Pain Assessment & Management," dated March 15, 2025, was reviewed. The policy indicated, "...[facility name] recognizes the patient's right to pain relief...Pain management shall be individualized, with consideration of the patient's clinical condition...to establish...pain management goals...Anticipatory Pain Management...Management involves anticipating and addressing potential sources of pain before they occur...Pre-procedure medications: For Procedures that are known to be painful...assess the patient's pain level and administer appropriate analgesia [pain medication] prior to the anticipated painful procedure..."

5.b. On July 16, 2025, at 9 a.m., a review of Patient 19's record was conducted with Regulatory Compliance Nurse (RC) 1.

A facility document titled, "H&P," dated July 14, 2025, was reviewed. The document indicated Patient 19 had a past medical history of diabetes, high blood pressure, and schizophrenic disorder. Patient 19 was sent from jail with concerns of dizziness and a ground level fall. The sheriff states he witnessed the fall, and patient did not lose consciousness. Patient reports mild frontal headache.

An untitled facility document dated, July 14, 2025, at 7 p.m. was reviewed. The document indicated, "...Pain Assessment: Pain Score: 6 [six, a pain level of 6 on the 0-10 pain scale is considered moderately strong pain], Patients Stated Pain Goal: No Pain, Pain Type: Acute Pain [a sudden, often sharp pain], Pain Location: Foot, Generalized, Pain Orientation: Right, Left..."

An untitled facility document dated, July 14, 2025 was reviewed. The document indicated no evidence of pain medication provided for Patient 19's six out of 10 foot pain.

During an interview, on July 16, 2025, at 9 a.m., conducted with RC 1, RC 1 stated there is no documented evidence showing Patient 19's pain was addressed nor was there any pain medication ordered by the physician.

The facility policy and procedure (P&P) titled, "Pain Assessment & Management," dated March 15, 2025, was reviewed. The policy indicated, "...[facility name] recognizes the patient's right to pain relief...Pain management shall be individualized, with consideration of the patient's clinical condition...to establish...pain management goals..."