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Based on record review and interview, the facility failed to ensure that nursing staff assessed ER patients per their presenting chief complaint and facility policy for 2 of 9 sampled patients (Patients # 8, 9). Nursing staff failed to conduct an initial pain assessment / reassessment per policy [ Patient ID # 9, 8]


Findings include:

TX00435293
TX00432449

Pain assessment /reassessment:

Record review of facility policy titled "ER Triage/Assessment/Reassessment," dated 02/2022, showed:

-Purpose: to provide assessment /reassessment guidelines for the specified chief complaint- to ensure the patient's changing needs are reassessed and appropriate care is provided.
-All patients presenting to the ER will be assessed to determine the severity of the presenting chief complaint.
-All patients are reassessed hourly.

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On 12/06/2022 in the ER , nine (9) electronic ER records were reviewed with Staff F, ER Manager. All findings were discussed and verified by Staff F at the time of review.

Patient ID# 9:

Review of Patient ID# 9's ER medical record showed she was a 61 year old female with a history of diabetes, who presented to the ER on 09/27/2022 at 3:52 PM. Chief complaint was "pain left leg." The ER medical provider documented "patient states she is having severe left posterior thigh pain since August that has progressively worsened." Patient described pain as sharp shooting pain. There was no documented pain assessment completed by nursing while Patient # 9 was in the ER.

Continued review of this ER record showed Patient # 9 was admitted to an inpatient bed on 09/27/2022 at 11:28 PM; length of stay in the ER was 7.5 hours.

Review of Patient # 9's inpatient record showed : shortly after arriving on the unit on 09/28/2022 at 0045, her pain level was assessed as "10/10." She was medicated with morphine 2 mg/ IV.

Patient ID #8 :

Review of Patient ID#8's ER medical record showed she was a 67 year old female admitted for worsening pain and some withdrawals symptoms. Patient # 8 had a pain pump placed 7 years ago and it malfunctioned 6 days ago. The ER medical provider documented "pain is constant- minimally improved by Norco- aching primarily down to her legs making it difficult to to ambulate. Severe." There was no documented pain assessment completed by nursing while Patient # 8 was in the ER.

During an interview on 12/06/2022 at 10:45 AM with Staff F, ER Manager , she said both Patient # 8 and 9 should have had pain assessments performed by nursing. Pain was their chief complaint.