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The hospital failed to comply with the provisions of 42CFR489.24 when it failed to provide an ongoing process of MSE (medical screening examinations) for two of 43 patients reviewed (Patients 1 and 17) when the assessments of the patients' pain were omitted, inconsistent and/or inaccurate. In addition, the hospital also failed to provide stabilizing treatment for Patient 17 as the patient's continuing pain received no further diagnostic work-up to determine the underlying cause of the pain.

Cross Reference A-2406, and A-2407.

Based on interview and record review, the hospital failed to provide an ongoing process of MSE (medical screening examinations) for two of 43 patients reviewed (Patients 1 and 17) as shown by omitted, inconsistent or inaccurate assessments of pain.

For Patient 17, the patient was discharged from the ED with continuing complaints of moderate abdominal pain. The patient sat in the ED waiting room for the next six hours before again presenting himself to the ED for treatment of the same abdominal pain, by then rated by the patient as severe. There was no further diagnostic screening examination done to ascertain if a medical emergency condition existed for Patient 17. The patient was discharged twice for the same reason and was asked to leave the ED waiting area by the hospital security staff per request of nursing; however, there was no documentation to show patient's pain was reassessed or was even asked to state his perception of his level of pain at the time of discharge. Patient 17 was found face down in the bushes on the hospital campus approximately one hour later and was unable to be resuscitated.

For Patient 1, the patient was discharged from the ED after complaints of moderate oral pain and facial swelling with no documentation to show the patient was asked to state his numerical level of pain at the time of discharge. The patient returned to the ED seven and a half hours later complaining of severe pain. After treatment with narcotic pain medication the patient was discharged with "improved" pain; however, there was again no documentation to show the patient's stated pain level.

Findings:

The hospital's policy on Pain Assessment and Management (formulated 7/08, reviewed 8/11) indicated that the patient's primary care physician/admitting physician would be responsible for the initial evaluation of pain, including appropriate diagnostic work-up to determine the cause of pain. "Changes in pain patterns or the development of new pain should not be attributed to pre-existing causes, but should trigger diagnostic evaluation (AHCPR)." Policy 13.0 stated, "Any indication that may demonstrate ineffectiveness of the analgesic treatment (moaning, grimacing, restlessness, increased heart rate and respiratory rate, loss of appetite and change in activity) will indicate change in treatment plan."

The Pain Assessment and Management policy would be used by all clinical staff, including physicians, who were all directly involved in patient care and read in part. "Staff will assess and monitor patients for presence of pain. They will encourage patient self-reporting of pain by asking the patient about their pain and by remembering that pain is what the patient says it is ...," and "All patients will be screened for pain at the time of admission," and, "Pain will be monitored throughout the patient's stay in the hospital; with each set of vital signs ..., and PRN. Response to pain relieving interventions will be documented based on the mode of pain medication delivery (i.e., IV-15 minutes, IM-30 minutes, PO-1 hour). Pain assessment will be documented and be communicated at points of transition of care, such as transfer, discharge or referral ..."

Pain scores are documented as the actual score versus the total possible score. The pain levels were rated on a scale of 0-10. Severe pain: a pain level of 7, 8, 9 or 10; Moderate pain: a pain level of 3, 4, 5 or 6; No pain: a pain level stated as "0." A score of 4 or greater indicates the need for pain relieving interventions. The staff would rely on the patient's self-report of pain, and response to pain relieving interventions would be documented based on the mode of pain medication delivery: intravenous medications (IV) 15 minutes, intramuscular (IM) injections 30 minutes and oral medications (PO) one hour.

1. The medical record for Patient 17 was reviewed on 9/6/12. The patient was was brought by ambulance to the ED on 6/18/11, complaining of abdominal pain. At 1825 hours, the triage nurse rated Patient 17's abdominal pain as 10/10. The physician's H&P dated 6/18/11, showed the patient reported daily drinking, abdominal pain and vomiting. IV morphine sulfate 5 mg (potent narcotic pain medication) was administered at 1842 hours, while a liter of IV fluid (normal saline) was infused for hydration. An anti-nausea medication (Zofran 4 mg) was given to relieve his vomiting. At 1844 hours, Patient 17 was given a "GI cocktail" by mouth, a combination of 20 ml of lidocaine viscous 2%, Maalox 30 ml, belladonna alkaloids 16.2 mg, and 5 ml of phenobarbital elixir (used to relieve gastric/epigastric pain). The 5 mg IV morphine dose was repeated at 1926 hours. There was no documentation of a pain reassessment 15 minutes to an hour after the IV pain medication was given, as per policy to evaluate the effectiveness of the pain intervention.

Review of RN 5's notes dated 6/18/11 at 1914 hours, revealed Patient 17 was restless. "The patient was standing up and does not want to lay down. Patient keeps flexing right arm which is preventing the fluids from running." At 1941 hours, RN 5 documented the patient climbed out of bed because he wanted to use the restroom. Patient repeatedly saying, "It hurts man." RN 5 documented "does not appear to be in pain."

The next pain reassessment documented on 6/18/11 at 2158 hours, showed Patient 17 had a pain level of five, 46 minutes after 1 mg of IV Dilaudid (pain medication) was administered at 2112 hours.

Review of Patient 17's H&P by MD 3 showed there were no gallstones via sonogram. The KUB x-ray (KUB -kidney, ureter and bladder) showed no evidence of obstruction. The abdominal ultrasound result showed the aorta was not well visualized due to "patient's large body habitus." There were no other follow-up examinations documented to visualize the aorta; however RN 5 documented on 6/18/11 at 2158 hours, Patient 17 was sent for a CT (computerized tomography) scan. There was no physician's order for a CT scan of the abdomen and no CT was completed.

Patient 17's abnormally high heart rate was attributed to alcohol intoxication (alcohol level of 166 mg/dL) without any description of Patient 17's pain level of 5/10. No additional diagnostic procedures were done to further examine the patient and assess the cause of the patient's pain to ascertain if an emergency condition existed.

At 2315 hours, Patient 17 was given a bus pass and discharged from the ED with diagnoses of Gastritis and Alcohol Intoxication. RN 5's discharge notes showed Patient 17's abdominal pain remained at a level of 5/10 and was "tolerable." The patient's heart rate remained abnormally high at 110 despite infusion of a liter of IV fluids to alleviate possible dehydration. No additional medication was given to relieve Patient 17's stated pain level of five. The patient was informed he could go to the ED waiting area until the following morning when the buses arrived.

On 9/6/12, review of the hospital's patient discharge instructions on Gastritis read, "Get help right away if you have more stomach pain and you are not improving or are getting worse."

Patient 17 remained in the ED's waiting area after his discharge from 2315 hours to the following morning. At 0506 hours on 6/19/11, instead of taking the bus home, Patient 17 again presented himself to the ED's triage area. The patient complained of abdominal pain was then rated at 10/10.

MD 2 reviewed Patient 17's record of the previous night's ED admission. Patient 17 was given an anti-nausea medication (Zofran 4 mg) and another GI cocktail by mouth. A repeat EKG (electrocardiogram) showed a fast heart rate at 105 beats per minute. MD 2's documentation showed repeat laboratory tests were not indicated, including a CT scan. Patient 17 "felt better" and would be discharged.

Review of the discharge notes entered by LVN 1 and "reviewed by RN 7" showed Patient 17 was no longer anxious but was calm "with no outward signs and symptoms of pain." No numerical level of pain was documented. There was no documentation by RN 7 to show the RN had reviewed and agreed with the LVN's findings. Patient 17 was assessed as stable without evidence his pain level was appropriately assessed. There was no documentation to show Patient 17 was even asked about his pain by any clinical staff, including the physician, per the hospital's policy.

In an interview with the Security Manager on 9/7/11 at 1100 hours, he stated Security Staff 1 (SS 1) was asked by LVN 1 to see Patient 17 who was "still in the waiting area after being discharged twice from ED." SS 1 approached Patient 17 and asked the patient to leave the waiting area. At 0852 hours, SS 1 received a call from an employee who saw Patient 17 "face down on the bushes" on the hospital campus. 911 was called by RN 7 who showed up at the scene in response to SS 1's call. Resuscitation efforts commenced but to no avail.

The autopsy findings for Patient 17 done on 6/20/11, showed an aortic dissection (a tear in the wall of aorta- the largest arterial blood vessel) with cardiac tamponade (squeezing pressure caused by the accumulation of blood/fluid around the heart), enlarged heart, fatty liver and chronic gastritis.



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2. Patient 1 came to the ED on 6/2/12 at 1141 hours with a complaint of pain and facial swelling. The pain was rated at 5/10 during triage at 1206 hours.

The physician's assessment at 1242 hours indicated Patient 1's pain was "constant" and "severe," but did not include a numerical rating. Oral pain medication (Vicodin 1 tablet) was administered at 1259 hours, and IM pain medication (Toradol 60 mg) was administered at 1300 hours; however, there was no rating of the patient's pain level recorded at those times. There was no pain assessment 30 minutes after the IM pain medication. The only subsequent pain assessment occurred at 1352 hours, when the RN assessment indicated, "pain better per pt (patient)" without a numerical rating of the pain. The patient was discharged at 1354 hours with prescriptions for an antibiotic and an oral pain medication.

At 2136 hours, on the same day Patient 1 returned to the ED with increased swelling and complaining of pain now rated as 10/10 during triage at 2206 hours. The patient was treated with an IV pain medication (Dilaudid) at 2247 hours, and again at 0027 hours, for pain levels of 9-10/10 and 7-8/10. At 0037 hours, the patient's pain was recorded as "improved" and he was discharged at 0038 hours; however there was no documentation of the patient's stated pain level.

During an interview with the ED Manager on 9/7/12 at 1200 hours, the record of Patient 1 was reviewed. The Manager concurred there was no quantified assessment of Patient 1's pain after triage or prior to discharge during his first visit to the ED on 6/2/12. The Manager stated "improved" did not provide an adequate description of the patient's pain level prior to discharge from his second visit.

Based on interview and record review, the facility failed to complete and document stabilizing treatment when Patient 17's continuing pain did not receive further diagnostic work-up to determine the underlying cause of pain, creating the risk of untreated pain with no stabilization of a medical condition for this patient.

Findings:

The hospital's policy on Pain Assessment and Management (formulated 7/08, reviewed 8/11) indicated the patient's primary care physician/admitting physician would be responsible for the initial evaluation of pain, including appropriate diagnostic work-up to determine the cause of pain. "Changes in pain patterns or the development of new pain should not be attributed to pre-existing causes, but should trigger diagnostic evaluation (AHCPR)." Policy 13.0 stated, "Any indication that may demonstrate ineffectiveness of the analgesic treatment (moaning, grimacing, restlessness, increased heart rate and respiratory rate, loss of appetite and change in activity) will indicate change in treatment plan."

The hospital's policy, Pain Assessment and Management (formulated 7/08, reviewed 8/11), indicated it was for use by all clinical staff and read in part, "Staff will assess and monitor patients for presence of pain. They will encourage patient self-reporting of pain by asking the patient about their pain and by remembering that pain is what the patient says it is ...," and "Pain assessment will be documented and be communicated at points of transition of care such as transfer, discharge or referral ..." The policy further read "Pain scores are documented as the actual score versus the total possible score. A score of 4 or greater indicates the need for pain relieving interventions" and "Severe pain: a pain level of 7, 8, 9 or 10 on the 0-10 scale; Moderate pain: a pain level of 3, 4, 5 or 6 on the 0-10 scale; No pain: a pain level stated as "0" on the 0-10 scale."

1. The medical record for Patient 17 was reviewed on 9/6/12. The patient was brought by ambulance to the ED on 6/18/11, complaining of abdominal pain. At 1825 hours, the triage nurse rated Patient 17's abdominal pain as 10/10. The physician's H&P dated 6/18/11, showed the patient reported daily drinking, abdominal pain and vomiting. IV morphine sulfate 5 mg (potent narcotic pain medication) was administered at 1842 hours, while a liter of IV fluid (normal saline) was infused for hydration. An anti-nausea medication (Zofran 4 mg) was given to relieve his vomiting. At 1844 hours, Patient 17 was given a "GI cocktail" by mouth, a combination of 20 ml of lidocaine viscous 2%, Maalox 30 ml, belladonna alkaloids 16.2 mg, and 5 ml of phenobarbital elixir (used to relieve gastric/epigastric pain). The 5 mg IV morphine dose was repeated at 1926 hours. There was no documentation of a pain reassessment 15 minutes to an hour after the IV pain medication was given, as per policy to evaluate the effectiveness of the pain intervention.

Review of RN 5's notes dated 6/18/11 at 1914 hours, revealed Patient 17 was restless. "The patient was standing up and does not want to lay down. Patient keeps flexing right arm which is preventing the fluids from running." At 1941 hours, RN 5 documented the patient climbed out of bed because he wanted to use the restroom. Patient repeatedly saying, "It hurts man." RN 5 documented "does not appear to be in pain."

The next pain reassessment documented on 6/18/11 at 2158 hours, showed Patient 17 had a pain level of 5/10, 46 minutes after 1 mg of IV Dilaudid (pain medication) was administered at 2112 hours.

At 2315 hours, Patient 17 was given a bus pass and discharged from the ED with diagnoses of Gastritis and Alcohol Intoxication. RN 5's discharge notes showed Patient 17's abdominal pain remained at level of 5/10 and was tolerable. The patient still had an abnormally high heart rate of 110 despite an infusion of a liter of IV fluids to alleviate possible dehydration. According to the hospital's P&P, a score of 4 or greater indicated the need for pain relieving interventions. There was no additional medication given to relieve Patient 17's pain level of five. The patient was instructed he could go to the waiting area until the bus arrived the following morning. Patient 17's abnormally high heart rate was attributed to alcohol intoxication (alcohol level of 166 mg/dL) without any description of Patient 17's pain level of 5/10.

Patient 17 remained in the ED's waiting area after his discharge from 2315 hours to the following morning. At 0506 hours on 6/19/11, instead of taking the bus home, Patient 17 again presented himself to the ED's triage area. The patient complained of abdominal pain now rated at 10/10.

MD 2 reviewed Patient 17's record of the previous night's ED admission. Patient 17 was again given an anti-nausea medication (Zofran 4 mg) and another GI cocktail by mouth. A repeat EKG (electrocardiogram) showed a fast heart rate at 105 beats per minute. MD 2's documentation showed repeat laboratory tests were not indicated, including a CT scan. Patient 17 "felt better" and would be discharged.

Review of the discharge notes entered by LVN 1 and "reviewed by RN 7" showed Patient 17 was no longer anxious but was calm "with no outward signs and symptoms of pain." No numerical level of pain was documented. There was no documentation by RN 7 to show the RN had reviewed and agreed with the LVN's findings. Patient 17 was assessed as stable without evidence his pain level was appropriately assessed. There was no documentation to show Patient 17 was even asked about his pain by any clinical staff, including the physician, per the hospital's policy.

On 9/7/12 at 1105 hours, MD 2 was interviewed. The MD stated he felt a CT scan was not indicated for Patient 17 based on his examination along with stable vital signs and no peritoneal symptoms. MD 2 stated Patient 17 "felt better" after the GI cocktail and was discharged. When asked regarding the use of a numerical pain assessment, the MD stated, "Usually nurses document pain level."

On 9/7/12 at 1130 hours, the ED Manager confirmed there was no documented numerical reassessment of pain by the LVN or the RN, as per the hospital's policy on Patient 17's medical record when the patient was discharged on 6/19/11.