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Based on review of policy, procedures, and medical records and staff interview, it was determined the facility failed to ensure the Registered Nurse adhered to the policy for assessment and pain management of the Emergency Department patient for four (#2, #3, #7, #8) of seven patients sampled. This practice does not ensure patient goals are maintained and may have adverse outcomes.

Findings include:

1. Review of patient #2's medical record revealed the patient was triaged in the Emergency Department (ED) on 3/08/10 at 10:05 p.m. The triage record revealed the patient complained of upper and lower abdominal pain and was assigned a level 3. Review of the ED physician evaluation, no time noted, revealed the patient had a history of GERD (Gastroesophageal Reflux Disease), hypertension, hyperlipidemia, and dementia.

Review of the facility's policy and procedures, "Assessment of the Emergency Department Patient", last revised 02/09, revealed all patients presenting to the Emergency Center will be assigned a triage category and classified as Level 1, 2, 3, 4, or 5. For a patient assigned a Level 3: Urgent, the vital signs and assessment findings will be documented every 2 hours and/or as needed based on condition.

Review of the nursing documentation revealed the patient was assessed at 10:05 p.m. and medicated for pain at 10:26 p.m. as ordered by the physician. Review of the nursing documentation revealed the patient was reassessed at 11:00 p.m. and noted the abdominal pain had decreased. Review of the nursing documentation revealed the patient was not reassessed by a nurse until 3:30 a.m. There were no vital signs noted since 10:26 p.m. The facility failed to reassess the patient, per facility policy and assigned level, of every 2 hours. Interview with the Clinical Informatic Lead on 7/21/10 at 10:50 a.m. confirmed the above findings.

2. Review of patient #3's medical record revealed the patient was triaged in the emergency department on 3/08/10 at 10:38 p.m. The triage record revealed the patient complained of shortness of breath, body aches, fever, and diarrhea and was assigned a level 3. Pain was assessed as 10 of 10 on a scale of 1-10 with 10 being the worst. Review of the physician documentation revealed the patient was examined at 11:20 p.m. The physician documentation revealed the patient had a history of colon cancer and was receiving chemotherapy treatment, the patient had a colostomy, hernia, renal insufficiency, and diabetes mellitus. Review of the nursing documentation revealed an assessment was completed on 3/09/10 at 12:48 a.m. Nursing documented abdominal cramping, nausea, and pain as 10 out of 10. Review of the Medication Administration Record (MAR) documentation revealed the patient was medicated for pain with Morphine 4 mg (milligrams) at 1:35 a.m. Nursing documentation revealed the patient was reassessed for pain at 2:30 a.m. in which the nurse documented no change in pain status. Physician documentation revealed the patient was re-examined, no time noted.

Review of the facility's policy, "Pain Management", last revised 10/08, revealed nursing will notify the physician of the patient's unmet pain goals and request pain medication or an adjustment to the existing order.

The ED physician documented at 2:41 a.m. the hospitalist was called and the case discussed. Orders were received to admit the patient to the medical surgical unit with telemetry for dehydration and diarrhea. Documentation revealed at 4:00 a.m. the patient was reassessed for pain. Nursing documented a pain level of 10 out of 10. Review of the MAR and nursing notes revealed no pain medication or nursing intervention documented. Review of the medical record revealed the patient was not monitored with a telemetry monitor as ordered until 5:40 a.m. The facility failed to reassess the patient, per facility policy and assigned level, of every 2 hours. Nursing failed to follow physician orders of telemetry monitoring in a timely manner. Interview with the Clinical Informatic Lead on 7/21/10 at 12:45 p.m. confirmed the above findings.

3. Review of patient #7's medical record revealed the patient was triaged in the emergency department on 3/08/10 at 9:54 p.m. The patient complained of left sided chest pain with increased pain on inspiration. The patient's pain level was assessed as 5 out of 10 and assigned a level 3. Review of the record revealed a nursing assessment was completed at 9:54 p.m. Review of the physician evaluation, noted at 10:20 p.m., revealed the patient had a history of cardiac disease, diabetes, hypertension, and hyperlipidemia. The ED physician documented at 2:19 a.m. the hospitalist was called and the case discussed. Orders were received to admit the patient to the medical surgical unit with telemetry. Review of the nursing documentation revealed the patient was reassessed at 5:00 a.m. The facility failed to reassess the patient, per facility policy and assigned level, of every 2 hours. Interview with the Clinical Informatic Lead on 7/21/10 at 1:40 p.m. confirmed the above findings.

4. Review of patient #8's medical record revealed the patient was triaged in the emergency room on 3/17/10 at 12:35 a.m. and assigned a level 3. The patient arrived via ambulance as semi responsive and a hypoglycemic episode. The patient was treated at the scene for a blood glucose of 27 (reference range 80-120). Documentation revealed upon arrival the patient's blood glucose was 168. Physician evaluation at 1:15 a.m. revealed a history of diabetes and recent alcohol consumption. Review of the nursing documentation revealed the patient was assessed at 12:50 a.m. and 5:42 a.m. Review of the physician documentation revealed the patient was reassessed at 4:40 a.m. and the patient's condition improved and the patient was at pre-event baseline. Nursing documentation revealed the patient's blood glucose was re-checked at 8:00 a.m. and documented as 106. The patient was discharged home at 8:59 a.m. Nursing failed to reassess the patient, per facility policy and assigned level, of every 2 hours. Interview with the Clinical Informatic Lead on 7/21/10 at 2:40 p.m. confirmed the above findings.