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ADVENTHEALTH HEART OF FLORIDA
EMERGENCY SERVICES POLICIES
Tag No.: A1104
Based on medical record review, staff interview and review of policy and procedures it was determined the facility failed to ensure staff followed their policy for assessment/reassessment of a patient in the Emergency Department for one (#6) of eleven patients reviewed.
Findings include:
Patient #6, a pediatric patient, presented to the ED (Emergency Department) on 12/26/2014 at 6:04 p.m. with a chief complaint of a laceration type injury to the buttock area. At the time of triage the child's pain was assessed as 5 out of 10 on a pain scale of 1-10 with 10 being the most severe.
There was no evidence of an assessment to determine if the child was medicated for pain prior to arrival. Review of the nursing documentation revealed an RN (Registered Nurse) assessed the patient at 7:20 p.m. and noted the child appeared to be uncomfortable and complained of pain. There was no evidence of any pain intervention from the time of arrival at 6:04 p.m. until 7:41 p.m. when the child was administered pain medication intravenously.
Review of the facility policy "Assessment/Reassessment" effective 8/2014 stated on #10, a registered nurse is responsible for an assessment of pain on admission to the hospital in acute care, Day Surgery, ER, Triage or any patient presenting with complaints of pain in all settings. The policy stated (2) patients with impaired communication, cognitively impaired, confused elders, infants and children at high risk for under treatment of pain, for these patients use FLACC scale, for children ages 3 and older, Wong/Baker faces scale may also be used. A score of 4 or more on the FLACC or Wong/Baker scales may be considered inadequate pain control and intervention is required. The child's pain level at triage was noted as 5/10 with no pain level noted at 7:20 p.m. but documentation stating the child appeared uncomfortable and complained of pain.
Interview with the Risk Manager, Chief Nursing Officer and Chief Quality Officer on 2/5/2015 at approximately 3:10 p.m. confirmed the above findings.