HospitalInspections.org

A. Based on document review and interview, it was determined for 1 of 3 (Pt #9) patients reviewed for leaving against medical advice (AMA), the Hospital failed to ensure its AMA policy was followed. This has the potential to affect all patients serviced by the Emergency Department (ED), which serves approximately 4,875 patients monthly.

Findings include:

1. The Hospital policy titled "Discharges Against Medical Advise Occurring in the Emergency Area" (no date) was reviewed on 8/28/18 at approximately 2:00 PM. The policy stated "D. General Procedure: 2. Patients leaving after physician evaluation but prior to treatment completion and disposition by the Emergency Department physician and/or attending physician: a. Nursing personnel should immediately notify the treating Emergency Department physician of the patient's announced intent to leave..."

2. Pt #9 Date of Service: 6/20/18.
Chief Complaint: Substance Abuse and Jaw Pain. Pt #9's record was reviewed on 8/28/18 at approximately 12:30 PM. On 6/20/18 at 9:31 PM, ED nursing documentation stated "Patient educated about.... Patient refused to stay in hospital and went against medical advice... Patient refused to sign AMA paper work." There was no documentation of ED physician and/or attending physician notification of Pt #9 leaving AMA.

3. An interview was conducted on 8/28/18 at approximately 3:30 PM with the Executive Director of ED (E#4) and the Nurse Manager ED (E#5). Both had reviewed Pt #9's record and verbally agreed the record lacked ED physician and/or attending physician notification of Pt #9's leaving AMA. Both stated the respective physician should have been notified and it should have been documented in the record.

B. Based on document review and interview, it was determined for 1 of 1 (Pt #10) patient reviewed for pain management monitoring, the Hospital failed to ensure its pain management policy was followed. This has the potential to affect all patients serviced by the Emergency Department (ED), which serves approximately 4,875 patients monthly.

Findings include:

1. The Hospital policy titled "Pain Management" (no date) was reviewed on 8/28/18 at approximately 3:10 PM. The policy stated "IV. GUIDELINES/PROCEDURE D. Patient Monitoring 1. An appropriate pain scale will be utilized to assess pain... 2. The patient's level of sedation will be monitored before and following the administration... F. Pain Reassessments 2. Pain assessment will be documented on a pain assessment form and conducted between 30 minutes and 1 hour after administration of the dose depending on the route of the medication. 3. A reason for a delay in pain reassessments will be documented..."

2. Pt #10 Date of Service: 6/14/18.
Chief Complaint: Shoulder Pain, Motor Vehicle Accident. Pt #10's record was reviewed on 8/28/18 at approximately 1:40 PM.
a. On 6/14/18 at 5:45 PM, nursing documentation stated Pt #10 was given FentaNyl (a narcotic analgesic) 25 micrograms (mcg) intravenous (IV). There was no documentation of a pain reassessment 30 minutes to 1 hour after the narcotic administration.
b. On 6/14/18 at 7:29 PM, nursing documentation stated Pt #10 was given FentaNyl 50 mcg IV. There was no documentation of a pain assessment before or a pain reassessment 30 minutes to 1 hour after the narcotic medication administration.

3. An interview was conducted on 8/28/18 at approximately 3:30 PM with the Executive Director of ED (E#4) and the Nurse Manager ED (E#5). Both had reviewed Pt #10's record and verbally agreed the record lacked pain assessments/reassessments, in accordance with its policy.