HospitalInspections.org

Based on review of medical record, hospital policies and procedures, and staff interviews, it was determined that the nurse executive failed to ensure the Emergency Department nursing staff supervise and evaluate the nursing care provided to 1 of 1 patients (Patient #1) with a traumatic injury.
Failure includes:
1. lack of documentation of vital signs,
2. lack of documentation of pain levels/intensity expressed by patient,
3. lack of systemic assessments, and focused assessments.

Findings include:

1. Review of medical record for Patient #1 for the stay of [October 17, 2017 from 1643 hours till 2104] hours revealed initial pain documentation by Triage Registered Nurse (RN) #51 at 1644 hours (hrs) as 10/10 - indicating highest level of pain. Additionally the ESI (Emergency Severity Index) assigned level indicated a number "3", which requires two or more resources to be used in the Emergency Department (ED). Chief complaint by patient is documented as "...left lower extremity pain and swelling...."

Medical record reveals vital signs with blood pressure, pulse rate, oxygen saturation, temperature (Fahrenheit), respiratory rate (breaths per minute), weight, height, and pain level charted at 1644 hrs by RN #51 and again at 2103 hrs by RN #66. No further vital documentation is available.

Policy titled "Vital Signs", Policy #ED1014, last reviewed 7/2018 requires, "...Appropriate vital signs are recorded every 60 minutes while the patient is in the ED or more frequently as indicted...are recorded 15 to 30 minutes after an injectable sedative or narcotic has been administered...."

Employee #49 confirmed in interview September 12, 2018 that there was no further vital documentation in the medical record.

2. Review of medical record for Patient #1 for the stay of [October 17, 2017 from 1643 hours till 2104] hours revealed initial pain documentation by Triage Registered Nurse (RN) #51 at 1644 hours (hrs) as 10/10 - indicating highest level of pain. No further "pain" documentation or response to pain medication/interventions is charted till discharge at 2103 hrs by RN #66.

Medical record reveals documentation by ED RN #52 of administration of narcotic pain medication [Hydrocodone-APAP (acetaminophen) 5mg (milligram) / 325 mg, ordered at 1745 hours by provider Physician Assistant #7 at 1811 hours] There in no documentation of pain intensity prior to administration.

Medical record reveals focused assessment by ED RN #66 at [1911 hours] indicates response to "narcotic pain medication" as "...no adverse reaction...." - there is no documentation as to intensity of pain or response to prior interventions.

Medical record reveals focused assessment by ED RN #66 at [1956 hours] indicates [Morphine 4 mg given intramuscular]. Medical record does not contain assessment of pain / intensity / quality prior to administration.

Medical record reveals focused assessment by ED RN #66 at [2029 hours] indicates response to ["...Morphine IM] Response - no adverse reaction...." There is no documentation as to intensity of pain intervention.

Policy titled "Pain Management Guidelines", policy #HW1157GL, last reviewed 4/2017, requires "...Guideline is to provide guidelines for appropriate and safe pain management for all...The patient is to achieve an acceptable level of pain relief with minimal side effects...A complete pain assessment is to be performed on patients who present with pain...includes: location...description...intensity using developmentally appropriate pain scales...verbal rating using the 1 - 10 intensity scale...onset and duration...relieving factors...comfort / functional goal...Assess for changes in vital signs...Will be performed: With every complete nursing assessment...after pain management interventions have been initiated and sufficient time has elapsed for the benefit of the intervention to occur...Sedation assessment: Nursing staff caring for patients who are receiving opioid medication for pain management use...sedation scale to assess trends in the patient's level of sedation and institute appropriate interventions...Respiratory Assessment...during opioid therapy...assess...rate, depth, and regularity of respirations...greatest risk for opioid induced respiratory depression is during the first 24 hours...should be assessed at least every one to two hours...uncontrolled moderate to severe pain is treated emergently...."

Employee #49 confirmed in interview September 12, 2018 that there was no required pain documentation in the medical record. Further, s/he confirmed that there should be an "intensity scale" documented prior to administration and after administration indicating response to medication / intervention.

3. Review of medical record for Patient #1 for the stay of [October 17, 2017 from 1643 hours till 2104] hours revealed that Patient #1 has a ["...Obliquely oriented mildly comminuted fracture of the left fibular neck...closed displaced fracture of the medial malleolus of the tibia with widening of the medial tibiotalar clear space suggesting underlying ligamentous injury...."]

Initial focused assessment of Chief Complaint, Vitals, Medications, Allergies, Problems, History, and Assessments (abuse, nutritional, functional, learning, needs, fall risk, skin integrity) by Triage RN #51 [at 1643] hrs indicated "...Functional assessment...no impairments...Fall Risk Assessment...No risk factors identified...."

A "focused" assessment by ED RN #52 [at 1659] indicated "...General/ Neuro (Neurological) / Psych (Psychiatric): Oriented x 4. Alert. Extremities: Limited ROM (Range of Motion), extremity pulses are within normal limits. Neuro-vascular status intact to the extremity. [Left ankle:] tenderness and swelling. Skin: Skin is warm and dry...Cold pack applied...." Medical record does not reveal any documentation of pain intensity prior to application of cold pack or assessment of pain level after a reasonable amount of time has passed for intervention to work.

Medical record does not reveal any assessment of respiratory function prior to or after a narcotic administration.

Medical record does not reveal "...A plan of care...based on assessment, nursing diagnosis, and outcome identification...identify priorities for nursing actions, patient goals and patient outcomes...communicate plan of care to other health care providers to ensure continuity of care...Implement a plan of care based on assessment...Perform appropriate monitoring...." as required by policy titled "Standards of Emergency Nursing Practice", policy #ED1004, last reviewed 9/2018

Policy titled "Pain Management Guidelines", policy #HW1157GL, last reviewed 4/2017, requires "...Assess for changes in vital signs...after pain management interventions...along with reassessment of analgesic side effects when indicted (for example, sedation, nausea, vomiting...Sedation scale to assess trends...and institute appropriate interventions...easy to arouse...awake and alert...may increase opioid dose if needed...a comprehensive assessment of respiratory status accompanies sedation assessment...during opioid therapy carefully assess the rise and fall of the patient's chest to determine rate, depth, and regularity of respirations...listen to sounds of...respirations...should be assessed at least every one to two hours...."

Policy titled "Standards of Emergency Nursing Practice", policy #ED1004, last reviewed 9/2018, requires "...Evaluation...nurse evaluates and modifies the plan of care based on observable patient responses and attainment of expected outcomes. The patient's response to interventions is continually evaluated to determine progress toward resolution of immediate needs...Document patient responses to interventions and changes in patient's condition, and revises the plan of care as appropriate...."

Employee #49 confirmed in interview September 12, 2018 that there was not the required focused assessment, respiratory assessment, or patient responses to intervention documentation as required by above policies.