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Based on record review, interview and policy review, the facility failed to ensure patients who presented to the emergency department received a timely medical screening and failed to ensure patients who reported pain were reassessed periodically. This affected six (Patients #3, #11, #14, #15, #17 and #20) patients, of 20 medical records reviewed. The average daily census of the emergency department from January 2024 through July 2024 was 146.29.

See A1100 and A1112.

Based on record review, interview and policy review, the facility failed to ensure patients who presented to the emergency department received a timely medical screening and failed to ensure patients who reported pain were reassessed periodically. This affected six (Patients #3, #11, #14, #15, #17 and #20) patients, of 20 medical records reviewed. The average daily census of the emergency department from January 2024 through July 2024 was 146.29.

Findings include:

1. Patient #11 arrived at the facility's emergency department on 07/19/24 at 11:08 PM with a chief complaint of elevated blood pressure. Vital signs were obtained on 07/19/24 at 11:36 PM during triage. The next set of vitals signs were not obtained until 07/20/24 at 5:22 AM. Patient #11 did not receive a medical screening exam until 8:06 AM.

2. Patient #14 arrived at the facility's emergency department on 08/07/24 at 11:36 PM with a chief complaint of abdominal pain. The patient was triaged at 11:43 PM. Patient #14's pain level was not assessed. Patient #14's disposition was entered on 08/08/24 at 7:09 AM as left without being seen after triage.

3. Patient #15 arrived at the facility's emergency department on 09/12/24 at 11:54 AM with a chief complaint of abdominal pain. On 09/12/24 at 12:02 AM, Patient #15's pain level was rated a ten on a one to ten scale. Patient #15's pain level was not documented any additional times during the visit. Patient #15 left the facility against medical advice (AMA) on 09/12/24 at 6:02 PM.

4. Patient #17 arrived at the facility's emergency department on 09/17/24 at 7:50 PM with a chief complaint of abdominal pain. On 09/17/24 at 7:54 PM, Patient #17's pain level was rated a ten on a one to ten scale. Patient #17's pain level was not documented any additional times during the visit. Patient #17 left the facility AMA on 09/18/24 at 2:15 AM.

5. Patient #20 arrived at the facility's emergency department on 08/24/24 at 3:54 AM with a chief complaint of abdominal pain. On 08/24/24 at 4:51 AM, Patient #20's pain was rated a nine on a one to ten scale and on 08/24/24 at 6:01 AM, the pain was rated a ten. Patient #20's pain level was not documented any additional times during the visit. Patient #20 was transferred on 08/24/24 at 6:49 PM.

6. Patient #3 arrived at the facility's emergency department on 08/02/24 at 9:49 PM and was admitted to the facility on 08/03/25 at 8:05 AM. On 08/02/24 at 9:54 PM, Patient #3's pain level was rated a ten on a one to ten scale. Patient #3 received Dilaudid 0.5 mg IV (intravenous) on 08/03/24 at 5:06 AM and 08/03/24 at 6:30 AM. Patient #3's pain level was not reassessed while Patient #3 was in the emergency department.

During an interview on 09/23/24 at 9:33 AM, Staff A verified the above findings.

Review of the facility policy titled "Routine Care, Emergency Department Protocol", effective date 03/11/24, stated A complete initial triage/assessment is performed by a registered nurse (RN) on arrival. A RN under the direction of an ED (emergency department) physician may delegate to an ED paramedic tasks allowed in the Emergency Department scope of a paramedic. Licensed practical nurses, paramedics, clinical technicians and /or nursing assistants may begin patient care, data collection and application of physiologic monitoring devices on arrival as directed by an RN.

Measure and document vital signs
a. Temperature (T), pulse (P), respirations (R), blood pressure (BP), pain level (using appropriate pain scale and SpO2 as indicated) during initial assessment.
b. Recommendation in the electronic health record (EHR) for vital sign alert reminders are based on the following nursing/physician leadership recommendations which are based on the Emergency Severity Index (ESI) Score
Emergency Severity Index (ESI) Scores:
1= 15 minutes
2= 30 minutes
3= 60 minutes
4= 240 minutes
5= 300 minutes

Patient placement post triage
a. Patients are assigned to exam spaces based on their assessed needs and the capabilities of areas within the ED (emergency department). When space is not immediately available, patients will be monitored in Intake/Triage area. Nurse initiated protocols may be ordered and the patient returned to lobby to wait for the next appropriate bed.
b. Patients returned to the ED lobby will be instructed to notify caregivers of any change in condition (signs/symptoms) immediately. Patients will be reevaluated based on their initial acuity. A full set of vital signs should be taken on patients with an ESI (Emergency Severity Index) level of 2 every hour. ESI level 3, 4, and 5 should have a repeat set of vital signs every 2 hours. Any abnormal vital signs should be communicated to the triage or charge nurse. Patients should be communicated with frequently and kept informed of updates.

Complete secondary assessment based on chief complaint.

Measure pain severity using appropriate pain scale
1. Initial pain assessment
2. Provide nonpharmacological pain relief measures as indicated (i.e., ice, elevate).
3. Reassess patient's pain score (refer to pain management protocols).

Review of the facility policy titled "Pain Management of the Adult Patient Protocol", effective 04/12/22, stated to perform pain assessments for every patient:
- On admission
- Per routine care protocol
- With change in caregiver
- As needed or indicated
Interventions
1. Develop attainable goals in collaboration with the patient/family focusing on comfort and function as well as based on severity and duration of pain.
2. Develop a multimodal integrative pain management plan in collaboration with the patient, family, and healthcare team using both non-pharmacologic and pharmacologic interventions.
- Administer analgesics as ordered to prevent/minimize recurrence of pain.
- Administer adjuvant medications as ordered per physician/LIP.
- Implement non-pharmacologic interventions as available - Nonpharmacologic Pain Management Care Path. (See Appendix D for additional recommendations)
Reassessment, Monitoring, and Readjustments of Interventions
2. Reassess pain (duration, description, and location) at the timeframes listed below:
- Within 60 minutes after the administration of any type and/or route of a needed analgesic medication (consider route, onset & duration of pharmacological agent being used).
- When a clinician dose is given or basal rate increased in a Patient Controlled Analgesic (PCA) device (peripheral or epidural).
- After providing a non-pharmacological pain intervention.
- As determined by patient clinical status.