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A. Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for nursing assessment, the Hospital failed to ensure that the registered nurse (RN) supervised and evaluated the care of each patient by failing to ensure that a comprehensive assessment was completed.

Findings include:

1. On 1/24/2023, the Emergency Medical Service (EMS) report to the Hospital on 12/18/2022 at 10:54 PM was reviewed. The report indicated that Pt. #1 will be arriving in the ED (emergency department) in 5-7 minutes and that Pt. #1 had Cervical/C-Collar (a neck brace use to immobilize a person's neck).

2. On 1/23/2023, the clinical record for Pt. #1 was reviewed. Pt. #1 was brought to the Hospital on 12/18/2022 due to MVC (motor vehicular collision) and spinal cord injury at C1-C4 (cervical/part of the spinal column). The clinical record included:

- On 12/18/2022, the ambulance run sheet indicated, " ... Injury of neck ... (Pt. #1) found lying across front seats ... by passenger floor. (Pt. #1) is alert and talking to crew ... (Pt. #1) removed from vehicle, spinal immobilization administered and (Pt. #1) secured in (the ambulance) ..." Pt. #1 arrived in the Hospital's ED at approximately 11:01 PM.

- On 12/18/2022 at 11:27 PM, E #2 (ED/Emergency Department RN) documented that Pt. #1's vital signs were as follows: BP 103/61 (normal is 120/80), HR 76 (normal), respiration: 18 (normal), temperature: 97.8-degree Fahrenheit (normal) and oxygen level of 99% (normal). Pt. #1 was triaged with an ESI of 2 (emergency severity index, patient requiring vital signs every hour x 4 based on clinical presentation, then every two hours and within 60 minutes of departure). There was no nursing assessment of Pt. #1's C- Collar upon presentation to the ED.

3. On 1/23/2023, a change of shift report from E #2 was reviewed. E #2's assessments of Pt. #1 did not indicate if Pt. #1 has a C- Collar on or if the C-Collar collar was maintained.

4. On 1/24/2023, the Hospital's policy titled, "Copy of Standards of Care in the Emergency Department and Emergency Nurses Association Guidelines" (effective 6/2022) was reviewed and included, "... Process: 1. The Registered Professional Nurse (RN) performs a nursing assessment... 3... b. The patient should receive a comprehensive assessment within a reasonable amount of time after admission to the treatment area by an RN... e. The patient should be continuously assessed for changes and progress towards meeting outcome goal..."

5. On 1/24/2023 at approximately 12:50 PM, an interview was conducted with E #8 (ED Nurse Educator). E #8 stated, "I would expect that if a patient arrives with C-Collar, nurses will assess and document that the C-Collar is maintained. It is important to maintain the C-Collar when there is a risk for damage in the spine."

6. On 1/24/2023 at approximately 9:07 AM, an interview was conducted with E #5 (ED RN). E #5 stated that she was not sure about the assessment and documentation expectations for patients with C-Collar.

B. Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for pain management, the Hospital failed to ensure that the registered nurse (RN) supervised and evaluated the care for each patient by failing to ensure that an intervention and/or pain reassessment was provided, as required.

Findings include:

1. On 1/23/2023, the clinical record for Pt. #1 was reviewed. Pt. #1 was brought to the Hospital on 12/18/2022 due to MVC (motor vehicular collision) and spinal cord injury at C1-C4 (cervical/part of the spinal column). The clinical record included:

- On 12/18/2022 at 11:30 PM, E #2 (ED RN) documented that Pt. #1 had a pain of 8/10 (severe pain). There was no documentation that an intervention was provided nor a pain reassessment following the intervention.

- On 12/19/2022 at 3:00 AM, E #3 (ED RN) documented that Pt. #1 complained of pain with a score of 10/10 (severe pain). There was no documentation that an intervention was provided.

2. On 1/24/2023, the competency requirement checklists for ED RN (undated) were reviewed and included, "... Pain Management... Assesses and monitors all patients for signs and symptoms of pain... Promptly respond to patient's reports of pain... Reassess patients after administering therapies alternative to, or adjunct to, other interventions..."

3. On 1/24/2023 at approximately 12:50 PM, an interview was conducted with E #8 (ED Nurse Educator). E #8 stated that if a patient has a pain score of 8-10, the pain can be considered severe. Typically, the physician is notified to make the patient comfortable. E #8 stated that non-pharmacological comfort measures/interventions can be done such as repositioning.

4. On 1/24/2023 at approximately 2:00 PM, findings were discussed with E #9 (ED Manager). E #9 could not provide documentation that an intervention was provided and/or if pain reassessment was conducted for Pt. #1 following the intervention.