HospitalInspections.org

Based on policy review, medical record review and interview, the nursing staff failed to document reassessments and failed to monitor and document the effectiveness of pain medication for 1 of 3 (Patient #2) sampled patients who received care in the emergency department.

The findings included:

1. Review of the hospital policy "Triage Assessment, Acuity Levels and Emergency Department Reassessment" revealed, "...Once the medical screening has begun, the reassessment of the patient will be based upon Triage Acuity Level, changes in the patient medical condition, or physician order...Level 2 Emergent Conditions that are a threat to life or limb or function requiring rapid medical intervention or delegated acts...Reassessment Requirement- Minimum hourly...Vital signs [VS] are not a required component of the Reassessment, but VS assist in determination of the stability of patients...VS usually refer to temperature, pulse rate, and blood pressure but may include pulse oximetry...or pain scale for those patients presenting with pain as a component of presenting complaint..."

Review of the hospital policy "Medication Administration" revealed, "...Purpose: Provide guidelines for the safe administration of medications...Procedure...7. Medications for IV [intravenous] administration should be given according to the guidelines approved for that particular care area...Morphine sulfate...comments Monitor pain scale, blood pressure, respiratory status...Consider Oxygen saturation monitoring in general care areas..."

2. Medical record review for Patient #2 revealed a three year old female who presented to the hospital emergency department (ED) on 7/1/2023 at 1:30 PM with her mother. Patient #2's mother reported she had fallen off the bed and had an arm injury. The triage assessment was initiated at 1:39 PM and Patient #2 was assigned an acuity level 2- "Emergent". The triage nurse documented, "Obvious deformity to left forearm. Mom states patient fell off bed...Male caregiver reports he was home with patient, states she rolled off bed..." Vital signs were recorded as Pulse- 101, Respirations- 18, Temperature- 99.1, Pulse Oximetry (Ox)- 99% on room air, and weight 11.79 kilograms. A medical screening exam was initiated by the ED physician at 1:45 PM which included a physical assessment and orders for imaging to diagnose the fracture. The ED Physician ordered IV pain medication, but Patient #2's mother refused. The ED Physician ordered oral (liquid) pain medication which Patient #2 refused. The radiology report revealed an acute fracture of the distal radial diaphysis with apex ulnar and volar angulation with soft tissue swelling about the forearm. At 2:01 PM Patient #2's Pulse Ox was recorded as 100% and at 2:04 PM it was recorded as 99%. The ED Physician contacted a pediatric hospital with pediatric surgery capability and arrangements were made to transfer Patient #2 for further evaluation on 7/1/2023 at 2:23 PM, via Emergency Medical Services (EMS). At 2:32 the ED Physician discussed with Patient #2's Mother the need to treat Patient #2's pain related to the fracture and the Mother agreed to IV medications. On 7/1/2023 at 2:41 PM 2 milligrams (mg) of IV morphine and 2 mg of IV Zofran were administered to Patient #2. Patient #2 remained in the hospital emergency department until 8:30 PM, when EMS arrived to transport Patient #2 to the Pediatric hospital. No vital signs were documented for Patient #2 after 2:04 PM, even at the point of transfer to the Pediatric hospital. A nursing entry at 6:45 PM (four hours after the pain medication was administered) revealed, "Follow up: Pain is decreased" The nursing staff failed to timely document Patient #2's response to the pain medication and failed to document reassessments every two (2) hours as required.

In an interview on 9/7/2023 at 11:05 AM, RN #1 verified she was Patient #2's primary nurse after triage was completed when Patient #2 was taken to a room in the ED. RN #1 stated she did not administer the medications for Patient #2 because she was contacting Child Protective Services about the suspicious injury as instructed by the ED Physician. RN #1 stated other nursing staff in the ED were assisting her in the care for Patient #2. When asked how Patient #2 was monitored after the pain medication was administered and when she had been reassessed, RN #1 stated there was no physician order for continuous monitoring. RN #1 verified the last vital recorded was the Pulse Ox at 2:04 PM. RN #1 stated she would record vitals/reassess patient on an "as need basis."

In an interview on 9/7/2023 at 11:19 AM, the ED Nursing Director stated he expected staff to obtain vital signs prior to discharge. He further verified there were no vital signs recorded after the initial triage assessment at 1:39 PM.

In a telephone interview on 9/8/2023 at 9:05 AM, RN #2 verified she had assisted RN #1 by administering medication to Patient #2. RN #2 verified Patient#2's mother initially refused the IV medication, then later agreed when Patient #2 refused to take the oral liquid pain medication. When asked how Patient #2 was monitored after the IV Morphine was administered, RN #2 stated RN #1 was the primary nurse. RN #2 stated she was the charge nurse on 7/1/2023 and was helping in many capacities in the ED. RN #2 stated she did not care for Patinet #2 after the medication was administered. When asked how patients should be monitored after IV pain medication, RN #2 stated,"The standard is heart rate and Oxygen at least an hour after the medication and document the response to the medication..."

In an interview on 9/11/2023 at 10:25 AM, The ED Nursing Director stated the expectation was to check oxygen saturation and respirations after the IV Morphine was administered to Patinet #2. The ED Nursing Director verified nursing staff did not follow the hospital policy for monitoring Patient #2.