HospitalInspections.org

Based on staff interview, policy review, and medical record review, the hospital failed to ensure licensed nursing staff supervised and evaluated the nursing care for each patient by failing to assess the effectiveness of pharmacologic interventions for pain management per policy for 3 of 10 sampled Emergency Department (ED) patients (#1, #8, #2); failing to assess and/or reassess pain levels per policy for 6 of 10 sampled ED patients (#7, #4, #1, #8, #2, #3); and failing to assess and/or reassess vital signs (Temperature, Blood Pressure, Pulse, Respirations, Oxygen Saturation) per policy for 8 of 10 sampled ED patients (#6, #3, #7, #2, #1, #5, #4, #8).

The findings include:

Interview on 09/28/2010 at 1440 with the ED Manager revealed pain level and intensity is to be assessed upon admission to the ED, after the administration of pain medications, and before discharge from the department. Interview revealed a numerical pain scale, face, or verbal scale is to be utilized to document a patient's pain level. If the patient is unable to use a scale then there should be documentation in the nurse's note of observations indicating pain (i.e. facial grimacing, moaning, etc.). Interview revealed pain should be reassessed within 15 to 30 minutes of the administration of IV (intravenous) medications and within 30 to 60 minutes of the administration of oral or IM (intramuscular) medications. Further interview revealed when a patient is discharged after receiving pain medication, pain is to be reassessed prior to discharge, even if discharge occurs less than 15 minutes following IV medication or less than 60 minutes following oral or IM medication. Interview revealed a complete set of vital signs (blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation) are expected to be obtained upon ED admission when triaged. Interview revealed the hospital's current policy Guidelines for Monitoring of Vital Signs in the Emergency Department was revised on 12/03/2009. Interview revealed the policy requires vital signs (within normal limits) to be repeated every two hours until the patient is discharged from the emergency department.

A. Review of current hospital policy "Pain Assessment and Management in Acute Hospital Setting" revised 06/2010, revealed "POLICY: ...Pharmacologic and Non-Pharmacologic interventions will be assessed for effectiveness and documented within one (1) hour after intervention."

1. Closed medical record review for Patient #1 revealed a 29 year-old female who presented to the ED on 09/28/2010 and was triaged by a registered nurse (RN) at 1840 with complaints of fall on right knee. Record review revealed the RN assessed the patient's initial pain level as 6/10 (numerical pain scale 0-10, 0 pain free, 10 worst pain). Record review revealed the patient was administered Anaprox (pain medication) two tablets orally at 2025. Record review revealed no documentation of reassessment for the effectiveness of the medication within one hour after intervention, nor prior to the patient's discharge at 2335 (3 hours 10 minutes later).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of reassessment for the effectiveness of the medication within one hour after intervention, nor prior to Patient #1's discharge at 2335 (3 hours 10 minutes later).

2. Closed medical record review for Patient #8 revealed a 61 year-old female who presented to the ED on 07/05/2010 and was triaged by a registered nurse (RN) at 1120 with complaints of a fall. Record review revealed the RN assessed the patient's initial pain level as 7/10 (numerical pain scale 0-10, 0 pain free, 10 worst pain). Record review revealed the patient was administered Percocet (pain medication) two tablets orally at 1230. Record review revealed no documentation of reassessment for the effectiveness of the medication within one hour after intervention, nor prior to the patient's discharge at 1422 (1 hour 52 minutes later).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of reassessment for the effectiveness of the medication within one hour after intervention, nor prior to Patient #8's discharge at 1422 (1 hour 52 minutes later).

3. Closed medical record review for Patient #2 revealed a 65 year-old female who presented to the ED on 09/24/2010 and was triaged by a registered nurse (RN) at 1455 with complaints of neck pain, right ankle pain, and right hip pain. Record review revealed the RN assessed the patient's initial pain level as 5/10 (numerical pain scale 0-10, 0 pain free, 10 worst pain). Record review revealed the patient was administered Tylenol (pain medication) 1 gram orally at 1615. Record review revealed no documentation of reassessment for the effectiveness of the medication within one hour after intervention, nor prior to the patient's discharge at 1620 (5 minutes later).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of reassessment for the effectiveness of the medication within one hour after intervention, nor prior to Patient #2's discharge at 1620 (5 minutes later).

B. Review of current hospital policy "Pain Assessment and Management in Acute Hospital Setting" revised 06/2010, revealed "STANDARD: Pain will be assessed and alleviated or reduced to a level of comfort that is acceptable to the patient in order to enhance the quality of life for the individual. POLICY: Pain assessment and management will be done by the RN and assisted by the LPN, using a scale 0-10, with a 0 being pain free and 10 being the most severe pain (worst possible pain) the patient has experienced. Adult patients are encouraged to use 0-10 numeric scale. If they cannot understand or are unwilling to use it, the smile-frown or the verbal scale is used. ..."

1. Closed medical record review for Patient #7 (visit #1) revealed an 86 year-old female who presented to the ED on 07/14/2010 and was triaged by a registered nurse (RN) at 1716 with complaints of witnessed fall, fell backwards hitting left shoulder, left hand, and head. Record review revealed no documentation the RN assessed the patient's initial pain level with a numerical pain scale, smile-frown or verbal scale upon ED admission per policy. Record review revealed no documentation of the reassessment of the patient's pain during the ED visit on 07/14/2010 between 1716 and 1930 (2 hours and 14 minutes).

Closed medical record review for Patient #7 (visit #2 - return within 24 hours of discharge) revealed an 86 year-old female who presented to the ED on 07/15/2010 and was triaged by a registered nurse (RN) at 1141 with complaints of evaluation of fall yesterday. Record review revealed no documentation the RN assessed the patient's initial pain level with a numerical pain scale, smile-frown or verbal scale upon ED admission per policy. Record review revealed no documentation of the reassessment of the patient's pain during the ED visit on 07/15/2010 between 1141 and 1640 (4 hours and 59 minutes). The patient was subsequently admitted for surgical repair of a right femur fracture.

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of Patient #7's initial pain assessment upon ED admission and no documentation of reassessment of the patient's pain during the ED visit (#1) on 07/14/2010 between 1716 and 1930 (2 hours and 14 minutes). Further interview confirmed no documentation of the reassessment of the patient's pain during the ED visit (visit #2) on 07/15/2010 between 1141 and 1640 (4 hours and 59 minutes).

2. Closed medical record review for Patient #4 revealed a 90 year-old female who presented to the ED on 08/11/2010 and was triaged by a registered nurse (RN) at 1045 with complaints of an unwitnessed fall from wheelchair and right hip pain. Record review revealed no documentation the RN assessed the patient's initial pain level with a numerical pain scale, smile-frown or verbal scale upon ED admission per policy upon. Record review revealed no documentation of the reassessment of the patient's pain during the ED visit on 08/11/2010 between 1045 and 1350 (3 hours and 5 minutes).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of Patient #4's initial pain assessment upon ED admission and no documentation of reassessment of the patient's pain during the ED visit (#1) on 07/14/2010 between 1716 and 1930 (2 hours and 14 minutes).

3. Closed medical record review for Patient #1 revealed a 29 year-old female who presented to the ED on 09/28/2010 and was triaged by a registered nurse (RN) at 1840 with complaints of fall on right knee. Record review revealed the RN assessed the patient's initial pain level as 6/10 (numerical pain scale 0-10, 0 pain free, 10 worst pain). Record review revealed no documentation of the reassessment of the patient's pain during the ED visit on 09/28/2010 between 1840 and 2335 (4 hours and 55 minutes).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of the reassessment of Patient #1's pain during the ED visit on 09/28/2010 between 1840 and 2335 (4 hours and 55 minutes).

4. Closed medical record review for Patient #8 revealed a 61 year-old female who presented to the ED on 07/05/2010 and was triaged by a registered nurse (RN) at 1120 with complaints of "Fall." Record review revealed the RN assessed the patient's initial pain level as 7/10 (numerical pain scale 0-10, 0 pain free, 10 worst pain). Record review revealed no documentation of the reassessment of the patient's pain during the ED visit on 07/05/2010 between 1120 and 1422 (3 hours and 2 minutes).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of the reassessment of the Patient #8's pain during the ED visit on 07/05/2010 between 1120 and 1422 (3 hours and 2 minutes).

5. Closed medical record review for Patient #2 revealed a 65 year-old female who presented to the ED on 09/24/2010 and was triaged by a registered nurse (RN) at 1455 with complaints of neck pain, right ankle pain, and right hip pain. Record review revealed the RN assessed the patient's initial pain level as 5/10 (numerical pain scale 0-10, 0 pain free, 10 worst pain). Record review revealed no documentation of the reassessment of the patient's pain during the ED visit on 09/24/2010 between 1455 and 1620 (1 hours and 25 minutes).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of the reassessment of Patient #2's pain during the ED visit on 09/24/2010 between 1455 and 1620 (1 hours and 25 minutes).

6. Closed medical record review for Patient #3 revealed a 9 year-old male who presented to the ED on 08/31/2010 and was triaged by a registered nurse (RN) at 1945 with complaints of left wrist and hand pain, and fever for several days. Record review revealed the RN assessed the patient's initial pain level as 2/10 (numerical pain scale 0-10, 0 pain free, 10 worst pain). Record review revealed no documentation of the reassessment of the patient's pain during the ED visit on 08/31/2010 between 1945 and 2045 (1 hour).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of the reassessment of Patient #3's pain during the ED visit on 08/31/2010 between 1945 and 2045 (1 hour).

C. Review of current hospital policy "Guidelines for Monitoring of Vital Signs in the Emergency Dept." revised 12/03/2009. revealed "Upon admission to the ED, vital signs of blood pressure, heart rate, respiratory rate, SpO2, and temperature will be obtained by the nurse or nursing assistant. If vital signs are within normal limits initially, vital signs will be repeated every two hours until discharge. ..."

1. Closed medical record review for Patient #6 revealed a 45 year-old female who presented to the ED on 07/27/2010 and was triaged by a registered nurse (RN) at 1740 with complaints of chest pressure. Record review revealed the RN assessed the patient's initial blood pressure, heart rate, and oxygen saturation. Further review revealed no documentation the RN assessed the patient's initial respiratory rate or temperature at triage. Record review revealed the patient was discharged at 2050. Record review revealed no documentation of the reassessment of the patient's vital signs every two hours per policy during the patient's ED visit on 07/27/2010 between 1740 and 2050 (3 hours and 10 minutes).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation the RN assessed Patient #6's initial respiratory rate or temperature upon ED admission at triage. Further interview confirmed no documentation of the reassessment of the patient's vital signs every two hours per policy during the patient's ED visit on 07/27/2010 between 1740 and 2050 (3 hours and 10 minutes).

2. Closed medical record review for Patient #3 revealed a 9 year-old male who presented to the ED on 08/31/2010 and was triaged by a registered nurse (RN) at 1945 with complaints of left wrist and hand pain, and fever for several days. Record review revealed the RN assessed the patient's initial heart rate, respiratory rate, temperature (100.2 degrees Farenheit) and oxygen saturation. Further review revealed no documentation the RN assessed the patient's initial blood pressure at triage. Record review revealed the patient was discharged at 2045. Record review revealed no documentation of the assessment of the patient's blood pressure or the reassessment of the patient's elevated temperature during the patient's ED visit on 08/31/2010 between 1945 and 2045 (1 hour).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of the initial assessment of the Patient #3's blood pressure or the reassessment of the patient's elevated temperature during the patient's ED visit nor prior to discharge on 08/31/2010 between 1945 and 2045 (1 hour).

3. Closed medical record review for Patient #7 (visit #1) revealed a 86 year-old female who presented to the ED on 07/14/2010 and was triaged by a registered nurse (RN) at 1716 with complaints of witnessed fall, fell backwards hitting left shoulder, left hand, and head. Record review revealed the RN assessed the patient's initial blood pressure, heart rate, temperature, and oxygen saturation. Further review revealed no documentation the RN assessed the patient's initial respiratory rate at triage. Record review revealed the patient was discharged at 1930. Record review revealed no documentation of the reassessment of the patient's vital signs every two hours per policy during the patient's ED visit on 07/14/2010 between 1716 and 1930 (2 hours and 14 minutes).

Closed medical record review for Patient #7 (visit #2 - return within 24 hours of discharge) revealed a 86 year-old female who presented to the ED on 07/15/2010 and was triaged by a registered nurse (RN) at 1141 with complaints of evaluation of fall yesterday. Record review revealed the RN assessed the patient's initial blood pressure, heart rate, respiratory rate, temperature and oxygen saturation. Record review revealed the patient was discharged at 1640. Record review revealed no documentation of the reassessment of the patient's vital signs every two hours per policy during the patient's ED visit on 07/15/2010 between 1141 and 1640 (4 hours and 59 minutes).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation the RN assessed Patient #7's initial respiratory rate upon ED admission when triaged. Further interview confirmed no documentation of the reassessment of the patient's vital signs every two hours per policy during the patient's ED visit (#1) on 07/14/2010 between 1716 and 1930 (2 hours and 14 minutes). Further interview confirmed no documentation of the reassessment of the patient's vital signs every two hours per policy during the patient's ED visit (#2) on 07/15/2010 between 1141 and 1640 (4 hours and 59 minutes).

4. Closed medical record review for Patient #1 revealed a 29 year-old female who presented to the ED on 09/28/2010 and was triaged by a registered nurse (RN) at 1840 with complaints of fall on right knee. Record review revealed the RN assessed the patient's initial blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation. Record review revealed the patient was discharged at 2335. Record review revealed no documentation of the reassessment of the patient's vital signs every two hours per policy during the patient's ED visit on 09/28/2010 between 1840 and 2335 (4 hours and 55 minutes).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of the reassessment of Patient #1's vital signs every two hours per policy during the patient's ED visit on 09/28/2010 between 1840 and 2335 (4 hours and 55 minutes).

5. Closed medical record review for Patient #5 revealed a 63 year-old male who presented to the ED on 08/05/2010 and was triaged by a registered nurse (RN) at 1817 with complaints of right lateral side and back pain. Record review revealed the RN assessed the patient's initial blood pressure, heart rate, respiratory rate, temperature and oxygen saturation. Record review revealed the patient was discharged at 2145. Record review revealed no documentation of the reassessment of the patient's vital signs every two hours per policy during the patient's ED visit on 08/05/2010 between 1817 and 2145 (3 hours and 28 minutes).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of the reassessment of Patient #5's vital signs every two hours per policy during the patient's ED visit on 08/05/2010 between 1817 and 2145 (3 hours and 28 minutes).

6. Closed medical record review for Patient #4 revealed a 90 year-old female who presented to the ED on 08/11/2010 and was triaged by a registered nurse (RN) at 1045 with complaints of an unwitnessed fall from wheelchair and right hip pain. Record review revealed the RN assessed the patient's initial blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation. Record review revealed the patient was discharged at 1350. Record review revealed no documentation of the reassessment of the patient's vital signs every two hours per policy during the patient's ED visit on 08/11/2010 between 1045 and 1350 (3 hours and 5 minutes).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of the reassessment of Patient #4's vital signs every two hours per policy during the patient's ED visit on 08/11/2010 between 1045 and 1350 (3 hours and 5 minutes).

7. Closed medical record review for Patient #8 revealed a 61 year-old female who presented to the ED on 07/05/2010 and was triaged by a registered nurse (RN) at 1120 with complaints of a fall. Record review revealed the RN assessed the patient's initial blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation. Record review revealed the patient was discharged at 1422. Record review revealed no documentation of the reassessment of the patient's vital signs every two hours per policy during the patient's ED visit on 07/05/2010 between 1120 and 1422 (3 hours and 2 minutes).

Interview on 09/28/2010 at 1440 with the ED Manager confirmed no documentation of the reassessment of Patient #8's vital signs every two hours per policy during the patient's ED visit on 07/05/2010 between 1120 and 1422 (3 hours and 2 minutes).

NC00066182