HospitalInspections.org

Based on medical record review, review of hospital policy and procedure and interviews, Emergency Department (ED) Nursing Staff failed to document nursing assessments related to the patient's chief complaint, response to medications administered and patient progress in the medical record. This failure affected four of twelve sampled patients, Patient Identifier (PI) Number (#) 1, PI # 2, PI # 3 and PI # 4.

Findings include:

Triage of PI # 1:

1). PI # 1 presented to the ED on 7/25/13 at 19:04 with a chief complaint of Abdominal Pain.
Urgent: 7/25/13 20:02
"nausea, vomiting"
Onset of symptoms: about seven days ago...
Patient is triaged to the ED waiting room.

Vital Signs:
7/25/13 at 20:02: Temperature: 98.2, Pulse: 103, Respirations:15, BP: 126/76, Pulse Oximetry: 100% (Room Air -RA). Pain 8/10.

Nursing Assessment: 7/25/13 20:02
Documented exactly as written:
"General
Neglect/Abuse: Survey shows Negative risk for this patient. "

Nursing Continuation Notes:

"Called to triage no answer." 7/25/13 19:54

Clinician (Physician) History of Present Illness:

Summary: ... presents to ED with complaints of lower abdominal pain, nausea and intractable vomiting. Onset @ 7 days ago. The patient is deaf...relaying his symptoms via sign language to...friend who is interpreting the history to MD (Medical Doctor) ...Patient complaining of lower abdominal pain, nausea,and intractable vomiting...Patient vague about urinary symptoms, but denies fever...

Exam started at 22:18. ...Abdominal pain is not well characterized. Symptoms are localized. Severity: currently moderate, but tolerable. Complaints of generalized abdominal pain...developed gradually over a period of several days...Has had recurrent vomiting (> 4) with intractable symptoms...nothing is staying down.


Progress Notes:

...Will admit patient...


Disposition:

...Discharge pain score 4/10...Disposition status is admit...Report...given...Patient physically left the department..


Drug Orders:

Zofran 4 mg (milligrams) IV (intravenous) - Dose given IV push. No complications. 7/25/13 22:41

After PI # 1 was triaged by the nurse at 20:02 on 7/25/13, there was no additional nursing documentation describing the patient's condition for over six hours or at the time of discharge from the ED and subsequent admission to the hospital at 02:26 on 7/26/13. There was no nursing assessment related to PI # 1's chief complaint of abdominal pain. There is no description of PI # 1's response to Zofran (medication to treat nausea) given at 22:41.

PI # 2:

2). PI # 2 presented to the ED on 7/24/13 at 10:57 with a chief complaint of vomiting. Morphine 4 mg. IV and Phenergan 12.5 mg. IV were given at 11:50 AM. Zofran 4 mg. IV was given at 15:05 and Morphine 4 mg. IV was given at 15:07. There is no nursing documentation describing PI # 2's response to the medications.

PI # 3:

3). PI # 3 was triaged on 7/25/13 at 14:43. The chief complaint was vomiting and "febrile adult." The Nursing Assessment revealed, "Neglect/Abuse: Survey shows negative risk for this patient." There is no nursing assessment related to PI # 3's chief complaint of vomiting and fever. The Drug Orders dated 7/25/13 reveal the patient was given Toradol 15 mg. IV at 1743 and Zofran 4 mg. IV at 1741. However, there is no nursing documentation describing PI # 3's response to the medication.


PI # 4:

4). PI # 4 presented to the ED on 7/25/13 and was triaged at 13:23. The chief complaint was vomiting. Drug Orders dated 7/25/13 reveal the patient was given Zofran 4 mg. IV at 16:41 and Toradol 30 mg. IV at 17:17. There is no nursing documentation describing PI # 4's response to the medication.



Policy and Procedure Review:

Title: Documentation of Care RC - 101
Last Revised: 7/2011...
"Nursing Assessment and Interventions: The Patient Care Record/Plan of Care will be utilized for all patients evaluated in the ED. Documentation must include the following: ...
F. Multi-system nursing assessment, as appropriate to the chief complaint...
Q. Medications administered and response to medication (only exception: tetanus and antibiotics).
R. Narrative documentation of:
1. Treatments or procedures implemented...
2. Nursing observations and interventions including:
a. Repeat vital signs
b. Patient progress/lack of progress
c. Reassessment findings
d. Evaluation...
f. Other pertinent data...
U. Appropriate disposition section completed including vital signs, unless documented in the last hour, condition, reassessment of pain..."

Interviews:

During an interview on 8/14/2013 at 9:00 AM, the ED Nurse Manager, Employee Identifier (EI # 1), stated ED medical records should contain:

- a nursing assessment relative to the patient's chief complaint;

- documentation about the patient's condition/ patient monitoring while being treated in the ED; and

- reassessment/response of patient after medication administration by the nurse.

The Manager verified that there was no nursing assessment relative to PI # 1's chief complaint documented in PI # 1's ED medical record on 7/25/13. There was no documented response to the medication given to PI # 1 and PI # 2. There was no nursing assessment related to PI # 3's chief complaint of vomiting and fever. PI # 3's and PI # 4's response to medications administered in the ED was not documented.