HospitalInspections.org

Based on record review, interview and policy review the nursing staff did not ensure patient vital signs and pain assessments are conducted in accordance with facility standards in 4 of 12 records reviewed.

Findings include:

Review of policy Clinical Practice: EC & WICC Standards of Care last revised 08/31/16 revealed for Emergency Severity Index (ESI) 1, 2 and 3, nursing assessments and vital signs are taken initially and then every 2 hours or more frequently with hemodynamic instability or change in patient clinical status in the Emergency Center environment.

Review of Patient #2 ED medical record dated 03/14/18 at 9:36 PM revealed an ESI score of 2 was assigned on triage with blood pressure noted to be 203/81. At 11:37 PM the patient was discharged to home with no documentation to indicate blood pressure was re-checked prior to discharge.

Interview on 08/16/18 at 09:55 AM with Staff (CC), ED RN indicated that she will get vital signs within an hour of patient discharge from the ED.

Interview on 08/16/18 at 10:00 AM with Staff (O), ED RN revealed that ED nursing is taught to take vital signs within an hour of discharge.

Review of facility policy titled "Pain Management" - NP S13, last revised 4/1/2017 revealed that Pain scale is to be utilized for the patient to accurately determine effectiveness of treatment within 60 minutes of administering pain medications. Pain re-assessment, pain scale, intensity and acceptability to patient is to be documented.

Review of medical records for Patient #6-8 on 8/14/18 at 1:15 PM revealed during Patient #6's admission of 6/8/18, there were 16 instances where there was no evidence of pain re-assessment within one hour of receiving pain medication. For Patient #7, there were 3 instances during their 8/18/18 admission and for Patient #8, there were 2 instances during their 8/6/18 admission.

Interview with Staff (M), RN on 08/14/18 confirmed that pain re-assessment should be documented, but was not.