HospitalInspections.org

Based on hospital policy and procedure review, medical record review, incident reports review and staff interviews, the hospital nursing staff failed to ensure a patient's pain was reassessed after a medication intervention for 3 of 3 sampled medical records with pain interventions (#1, #2 and #3); and failed to ensure a patient in handcuffs and shackles was monitored to prevent a fall for 1 of 3 patient falls reviewed (#12).

Findings included:

A. Review on 07/20/2017 of the hospital policy and procedure titled "Pain Management", last revised 02/14/2017, revealed "Purpose To provide our patients with prompt and effective control of pain. Policy...C. Pain Assessment Guidelines (level/description) and Documentation...b. Approximately one hour after a pain intervention..."

1. Review of the medical record on 07/18/2017 for Patient #1 revealed a 70-year-old male admitted to the hospital on 06/02/2017 with a chief complaint of bilateral hip pain and thigh pain. Patient #1 was discharged on 06/14/2017 at 1307. Review of the discharge summary documented on 06/14/2017 at 0815 revealed "DISCHARGE DIAGNOSES: Diffuse large B-cell lymphoma. 2. Pending pathological fractures, status post pathologic Gamma nailing, bilateral hips. 3. Pain secondary to above (#1 and #2). 4. Impaired mobility secondary to fracture and surgery..." Review of the Medication Administration Record (MAR) revealed Patient #1 was administered Dilaudid (pain medication) 4 mg (milligrams) po (by mouth) on 06/02/2017 at 2138 with a pain reassessment documented on 06/03/2017 at 0000 (1 hour and 22 minutes late). Further review of the MAR revealed Dilaudid 4 mg po was administered on 06/04/2017 at 1615 with a pain reassessment documented on at 1755 (40 minutes late). Review of the MAR revealed Patient #1 was administered Dilaudid 2 mg IV (intravenous) on 06/03/2017 at 0429 with a pain reassessment documented on at 0800 (2 hours and 31 minutes late). Review of the MAR revealed Dilaudid 2 mg IV was administered on 06/03/2017 at 1250 with a pain reassessment documented at 1600 (2 hours and 10 minutes late). MAR review revealed Dilaudid 2 mg IV was administered on 06/04/2017 at 0600 with a pain reassessment documented at 0800 (1 hour late). Review of the MAR revealed Dilaudid 2 mg IV was administered on 06/04/2017 at 1347 with a pain reassessment documented at 1600 ( 1 hour and 13 minutes late) Continued review of the MAR revealed Dilaudid 2 mg IV was administered on 06/04/2017 at 1755 with a pain reassessment documented at 2000 (1 hour and 5 minutes late). MAR review revealed Dilaudid 2 mg IV was administered on 06/052017 at 0430 with a pain reassessment at 0800 (2 hours and 30 minutes late).

Interview during medical record review on 07/18/2017 at 1600 with nurse manager #1 revealed the staff should reassess pain level within 1 hour of pain medication intervention per the hospital policy. Interview revealed the nursing staff failed to follow the hospital policy on pain management.

2. Review of the medical record on 07/20/2017 for Patient #2 revealed a 51-year-old female admitted to the hospital on 05/31/20117 at 2239 with a diagnosis of Acute Septic Arthritis and was discharged on 6/08/2017 at 1945. Review of the MAR revealed Demerol (pain medication) 50 mg IV was administered on 05/31/2017 at 1936 with a pain reassessment documented at 2325 (2 hours and 49 minutes late). MAR review revealed Demerol 50 mg po was administered on 06/01/2017 at 0007 with a pain reassessment at 0400 (2 hours and 53 minutes late). Review of MAR revealed Toradol (pain medication) 30 mg IV was administered on 06/01/2017 at 2225 with a pain reassessment at 0000 (35 minutes late). MAR review revealed Ultram (pain medication) 50 mg po was administered on 06/03/2017 at 2049 with a pain reassessment at 2357 (2 hours and 8 minutes late). Continued review of MAR revealed Toradol 30 mg IV was administered on 06/04/2017 at 0416 with a pain reassessment documented at 0800 (2 hours and 53 minutes late). MAR review revealed Ultram 50 mg po was administered on 06/04/2017 at 1318 with a pain reassessment at 1600 (1 hour and 42 minutes late). Continued review of MAR revealed Toradol 30 mg IV was administered on 06/04/2017 at 1610 with a pain reassessment documented at 2000 (2 hours and 50 minutes late).

Interview during medical record review on 07/20/2017 at 1100 with nurse manager #1 revealed the staff should reassess pain level within 1 hour of pain medication intervention per the hospital policy. Interview revealed the nursing staff failed to follow the hospital policy on pain management.

3. Review of the medical record on 07/20/2017 for Patient #3 revealed a 63-year-old female admitted to the hospital on 07/16/20117 at 1825 with a diagnosis of Deep Vein Thrombosis and was discharged on 07/18/2017 at 1524. Review of the MAR revealed Percocet (pain medication) two (2) tablets po was administered on 07/16/2017 at 1630 with a pain reassessment documented at 1940 (2 hours and 10 minutes late). Review of the MAR revealed Percocet two (2) tablets po was administered on 07/17/2017 at 2027 with a pain reassessment documented at 0000 (2 hours and 33 minutes late).

Interview during medical record review on 07/20/2017 at 1100 with nurse manager #1 revealed the staff should reassess pain level within 1 hour of pain medication intervention per the hospital policy. Interview revealed the nursing staff failed to follow the hospital policy on pain management.

B. Review on 07/19/2017 of the hospital policy and procedure titled "Interdisciplinary Assessment/Reassessment of Patients", revised 05/25/2017, revealed "...Nursing C. Unit Specific Assessment & Reassessment Criteria 8. Emergency Department...b. Reassessment The patient will be reassessed periodically based on complaint and acuity and will be monitored for changes and progress towards meeting desired outcomes and discharge/admission/transfer objectives. Reassessment may include patient condition, vital signs, pain level, behavior, or other parameters based on the patient's complaint and acuity."

Review on 07/20/2017 of the "Fall Assessment Criteria for Emergency Department Patients" dated November 2016 revealed "Patients that meet 3 or more of these criteria are to be considered as 'at risk for fall' and should have a yellow band placed on the wrist. Based upon individual patient assessment, nurses may deem patients as 'at risk for falls' with less than 3 indicators..."

Review on 07/19/2017 of the hospital policy and procedure titled "Care of the Psychiatric and Behavioral Health Patient in the Emergency Department", revised 10/01/2016, revealed "...Policy...4. Constant Observation b. Constant observation of patients placed in the ED (Emergency Department) safe rooms will be provided by one observer for up to 4 patients due to the video monitoring available in those rooms."

Review on 07/19/2017 of the hospital policy and procedure titled "Restraint Policy", revised 12/07/2016, revealed "...Procedure...C. Restraints Used By Law Enforcement Personnel (Forensic Restraints) 1. ...Patients in forensic restraints should be acknowledged, clinically assessed, and documented as being in custody of law enforcement..."

Review on 07/19/2017 of the falls log revealed the hospital had 3 documented falls in July, 2017. Review of the hospital incident reports on the falls documented in July, 2017 revealed a fall in the ED with patient #12 sustaining an injury.

Review on 07/19/2017 of the medical record for Patient #12 revealed a 51-year-old male that presented to the Emergency Department (ED) on 07/12/2017 at 1421 with a chief complaint of Altered Mental Status with Hallucinations. Review of the triage nursing assessment documented by a Registered Nurse (RN) at 1429 revealed Patient #12 was brought to the ED by local law enforcement from the county jail in handcuffs and shackles for altered mental status. Triage notes revealed report was called to the ED from the nurse at the jail. Triage notes revealed Patient #12 was alert and oriented to person and time. Further review of the triage nursing note revealed Patient #12 complained of blood pressure elevated with finger cramps, headache and nosebleeds. Triage notes revealed the patient became "belligerent and yelled at me..." Triage nursing notes revealed per the nurse at the jail Patient #12 is an "alcoholic and has not had anything to drink in 2 1/2 weeks. Pt (patient) reports he drinks a 40 oz plus a pint a day when he did drink. She reports eyes are jaundiced..." Triage assessment revealed past surgical history of facial surgery. Vital signs were blood pressure 125/97, pulse 103, respiratory rate 20, temperature 98.8 and pulse oximetry (Oxygen level) 96% on room air. Review of fall risk assessment, documented during triage, revealed Patient #12 had a score of 1 (positive for Mental Status Change indicator) and a yellow fall risk bracelet was applied. Review of the nursing notes revealed the patient was placed in a bed with one side rail up at 1435. Further review of nursing assessment revealed Patient #12 had a decreased level of consciousness with an abnormal neurological assessment. Further review of the nursing assessment revealed Patient #12 was alert, awake, oriented to person and disoriented to time and place. Nursing assessment revealed the patient's speech was clear, but was inappropriate and exhibited irritable behavior. Nursing neurovascular assessment revealed "Pt alert to name, not place or time, has moments of being a&ox3 (alert, oriented to person, place and time) but will then start talking to someone who is not in the room." Review of nursing patient notes documented at 1508 revealed Patient #12 was moved to a safe room for behavioral health evaluation. Review of physician orders revealed an order dated 07/12/2017 at 1515 for Geodon (medication for behavior) 20 mg IM (intramuscular injection) now, Cogentin (anti-Parkinson's disease medication) 2 mg IM now and Ativan (medication for anxiety) 2 mg IM now. Review of MAR revealed the Ativan 2 mg IM was administered at 1530 and the Geodon 20 mg IM and Cogentin 2 mg IM was administered at 1533. Nursing patient notes dated 07/12/2017 at 1603 revealed "pt sitting in chair at bedside, calm, relaxed, and drowsy..." Review of nursing notes revealed nursing rounds conducted at 1630 with documentation of Patient #12 asleep in the chair and "sedated". Review of nursing patient notes revealed documentation at 1701 "pt noted to be face down on the floor, small laceration noted to L (left) side of face near eye, moderate amount of blood noted and bruise to L side of face. Pt remains drowsy...pt situated into bed." Documentation at 1703 revealed forensic restraints removed by law enforcement. Vital Signs documented at 1807 revealed blood pressure 147/55, pulse 89, respiratory rate 20 and pulse oximetry 100% on room air. Nursing notes revealed the physician assistant sutured the laceration at 1930. Review of the record revealed Patient #12 was admitted on 07/12/2017 at 1944 and discharged on 07/14/2017 at 1453.

Observation during tour on 07/20/2017 at 1345 revealed the camera monitor was located in the hallway of the ED between rooms T16 and T17. Further observation of the camera monitor for rooms T14, T15, T16 and T17 revealed there was a delay (approximately 1-3 seconds) from the room to the monitor. Observation during tour revealed the Constant Observer (CO) has no direct visual into the four (4) rooms.

Interview on 07/20/2017 at 1229 with the Constant Observer revealed she was watching the camera monitor on 07/12/2017. Interview revealed she sat outside of the four (4) rooms and watched the patients on the monitor. Interview revealed there were four (4) patients on the monitors on 07/12/2017. Interview revealed Patient #12 walked to room T16 from room T4 and sat down in recliner. Interview revealed she heard a noise, looked up at the monitor and saw Patient #12 had fallen face first onto the floor. Interview revealed she notified the nurse and deputy that was sitting outside of Patient #12's door. Interview revealed "The camera has a delay."

Telephone interview on 07/21/2017 at 1259 with the Unit Secretary revealed she was working on 07/12/2017 during the incident. Interview revealed she did not have direct visualization of Patient #12's room from her desk. Interview revealed she had walked to the desk in front of room T16 to file some papers and "heard something like a boom". Interview revealed she saw Patient #12 in the floor at about the same time the Constant Cbserver saw patient on the camera monitor. Interview revealed the patient fell from a recliner. Interview revealed the Constant Observer remained in her chair and "I notified the charge nurse". Interview revealed the deputy was outside of the room. Interview revealed she was not sure if the deputy saw the patient fall from the chair. Interview revealed she did not recall where the deputy was sitting outside the room or if he was facing the door. Interview revealed the charge nurse responded and came to the room.

Interview on 07/20/2017 at 1238 with the Charge Nurse revealed she was the charge nurse on 07/12/2017. Interview revealed Patient #12 was moved to a safe room (T16) for safety due to auditory and verbal hallucinations. Interview revealed Patient #12 remained in forensic restraints (handcuffs and shackles) throughout his stay in the ED. Interview revealed Patient #12 attempted to leave the ED from room T4, "before the deputy stopped him as he was heading towards the door". Interview revealed she was not sure of the deputy's location when the patient exited the room (T4). Interview revealed Patient #12 was escorted to room T16 prior to receiving medications. Interview revealed the patient was sitting in the recliner with his "arms and legs still shackled together when the medications were administered. Interview revealed "I think the secretary saw him fall over." Interview revealed the patient was placed on the stretcher after the fall. Interview revealed "I don't recall where the officer was. They usually sit in a chair outside the room, facing the door." Interview revealed she received the information about the fall from the Paramedic student in the room as she was walking past the door. Interview revealed she was also notified by the Constant Observer.

Interview on 07/20/2017 at 0923 with ED Physician Assistant revealed she was working on 07/12/2017. Interview revealed the patient presented to the ED with Altered Mental Status and Psychosis. Interview revealed the "patient was sitting upright on the side of the bed when I assessed him in room T4". Interview revealed medications were ordered by the ED physician due to patient becoming belligerent with the nurses. Interview revealed a deputy was standing outside the patient's room door. Interview revealed the patient attempted to leave the ED and was stopped by the deputy. Interview revealed the patient was moved to a safe room (room T16). Interview revealed she was notified by the nursing staff of the patient's fall. Interview revealed she assessed the patient after the fall. Interview revealed the patient had a laceration on his nose and was bleeding from the right nostril. Interview revealed she ordered a Cat scan - Facial Bones. Interview revealed the patient was placed in the bed with side rails up.

Interview on 07/20/17 at 1400 with ED Physician revealed he was working on 07/12/2017. Interview revealed he ordered the Ativan, Geodon and Cogentin to "slow DT's (delirium tremors) while working up for medical clearance". Interview revealed the Ativan was ordered for the DT's, hallucinations and to help him relax. Interview revealed the Geodon was ordered for his auditory and verbal hallucinations and the Cogentin was ordered to prevent Extrapyramidal effects (tremors, dystonia, akathisia, and rigidity) that are sometimes seen after giving Geodon. Interview revealed the "medications were not used as a chemical restraint". Interview revealed he did not see the patient after the fall until the physician assistant was getting ready to suture his laceration.

NC00128621