HospitalInspections.org

Based on record review and interview, the facility staff failed to obtain and accurately document "Consent for Treatment and Financial Agreement" for 5 of 12 patients (Patients #2, #3, #5, #7, and #9) seeking care in the ED (Emergency Department) in a total of 12 records reviewed.

Findings include:

The facility policy titled "Patient Rights and Responsibilities" #7808885 last reviewed 3/2020, revealed: "PROCEDURE: [Facility Name] provides compassionate, personalized care to all. Patients (or support person) have the right, consistent with laws and regulations to: 4. Make informed decisions and provide consent about their care, treatment and services, unless they are unable to do so. Except in emergencies, patient consents or the consent of the patient representative shall be obtained before treatment is administered."

Patient #2's medical record reviewed with Quality and Patient Safety Coordinator D revealed, Patient #2 was a 27-year-old who presented to the ED on 11/09/2021 at 10:41AM with a chief complaint of extreme nausea. Patient #2 was evaluated and treated in the ED. There was no documented "Consent for Treatment and Financial Agreement" in Patient #2's medical record for this visit.

Patient #3's medical record reviewed with Quality and Patient Safety Coordinator D revealed, Patient #3 was a 72-year-old who presented to the ED on 11/09/2021 at 10:46 AM with a chief complaint of a lacerated finger. Patient #3 was evaluated and treated in the ED. There was no documented "Consent for Treatment and Financial Agreement" in Patient #3's medical record for this visit.

Patient #5's medical record reviewed with Quality and Patient Safety Coordinator D revealed, Patient #5 was a 68-year-old who presented to the ED on 11/16/2021 at 5:05 PM with a chief complaint of chest pain. Patient #5 was evaluated and treated in the ED. There was no documented "Consent for Treatment and Financial Agreement" in Patient #5's medical record for this visit.

Patient #7's medical record reviewed with Quality and Patient Safety Coordinator D revealed, Patient #7 was a 76-year-old who presented to the ED on 9/21/2021 at 2:49 PM with a chief complaint of right abdominal pain. Patient #7 was evaluated and treated in the ED. There was no documented "Consent for Treatment and Financial Agreement" in Patient #7's medical record for this visit.

Patient #9's medical record reviewed with Quality and Patient Safety Coordinator D revealed, Patient #9 was a 68-year-old who presented to the ED on 10/08/2021 at 4:20 AM with a chief complaint of opiate withdrawal. Patient #9 was evaluated and treated in the ED. There was no documented "Consent for Treatment and Financial Agreement" in Patient #9's medical record for this visit.

During an interview on 11/28/2021 at 10:42 AM with Quality and Patient Safety Coordinator D stated "The consent to treat is not completed for Patients #2, #3, #5, #7 and #9."

Based on record review and interview, staff failed to address patient's advanced directives in an outpatient setting (emergency department) in 5 of 12 out of a total of 12 medical records reviewed (Patient #1, #2, #3, #6 and #10.).

Findings include:

Record review of policy "Advance Directives" #9262440 last approved 2/16/2021 under Policy Implementation Inpatient and Ambulatory Settings revealed "patient 18 yrs old and older will be asked... whether he/she has an advanced directive... If a patient does not have advance directives, the patient will be asked if he/she would like additional information and/or assistance"

Patient #1's medical record reviewed with Quality and Patient Safety Coordinator D revealed, Patient #1 was a 27-year-old who presented to the ED on 11/09/2021 at 9:45 AM with a chief complaint of abdominal pain. The Epic (electronic medical record) triage question "Do you have advance directives?" was not addressed.

Patient #2's medical record reviewed with Quality and Patient Safety Coordinator D revealed, Patient #2 was a 27-year-old who presented to the ED on 11/09/2021 at 10:41 AM with a chief complaint of extreme nausea. The Epic (electronic medical record) triage question "Do you have advance directives?" revealed "NA" (not addressed).

Patient #3's medical record reviewed with Quality and Patient Safety Coordinator D revealed, Patient #3 was a 72-year-old who presented to the ED on 11/09/2021 at 10:46 AM with a chief complaint of a lacerated finger. The Epic (electronic medical record) triage question "Do you have advance directives?" was not addressed.

Patient #6's medical record reviewed with Quality and Patient Safety Coordinator D revealed, Patient #6 was a 31-year-old who presented to the ED on 11/06/2021 at 12:23 PM with a chief complaint of abdominal pain. The Epic (electronic medical record) triage question "Do you have advance directives?" was not addressed.

Patient #10's medical record reviewed with Quality and Patient Safety Coordinator D revealed, Patient #10 was a 40-year-old who presented to the ED on 11/11/21/2021 at 5:17 AM with a chief complaint of abdominal pain. The Epic (electronic medical record) triage question "Do you have advance directives?" was not addressed.

During an interview on 11/18/2021 at 10:42 AM with Emergency Department (ED) Manager C, ED Manager C confirmed, the question about advanced directives is on the triage questions for the Emergency Department nurses stating it "should be asked" on every patient.

Based on record review and interview, the facility failed to ensure appropriate ongoing nursing assessments in the Emergency Department (ED) per policy and procedures by failing to ensure a focused nurse assessment is completed by a registered nurse in a timely manner in 5 of 12 patients seen in the Emergency Department (Patient #2, #4, #6, #9, and #11) and failed to ensure nursing staff provide a pain assessment or reassessment in 4 of 8 patients presenting to the Emergency Department with pain (Patient #4, #5, #6 & #9) in a total of 12 Emergency Department records reviewed.

Findings include:

Record review of policy titled "Assessment-Reassessment - Patient" #8449380, last approved 8/12/2020 under Emergency Department (ED / Urgent Care (UC) under Scope of Assessment revealed "Each ED patient will be triaged... as soon as possible upon arrival... ED Patients will be moved to the examination room as soon as possible according to priority level and room availability... focused assessments will be done for each patient based upon established standards and guidelines to identify needs, plan and initiate care, and evaluate effectiveness of interventions... Focused assessments include evaluation of body systems(s) affected by the stated medical problem or abnormal findings(s)."

On 11/18/2021 at 8:35 AM during interview with Trauma Coordinator J and ED Lead R, Coordinator J stated they follow the Emergency Nursing Association's standards of care and the national standards for Emergency Department registered nurse (RN) assessments which include ED RN assessment completion time of "door to triage" in "10 minutes" and "door to RN" focused nursing assessment in "60 minutes".

Record review of policy "Pain Management Resource" #10705392 approved 11/09/2021 under Assessment revealed "Assess pain using organization-approved assessment tools." Under Reassessment revealed "Reassessment includes pain intensity/score, adverse effects, and sedation (for patients receiving opioid analgesics)... reassessment is 15-30 minutes after IV [intravenous] administration and 60-120 minutes after oral administration."

Patient #2's medical record revealed Patient #2 was a 27-year-old who presented to the ED 11/09/2021 at 10:40 AM with the chief complaint of extreme nausea. Patient #2 was triaged at 11:11 AM with an Emergency Severity Index (ESI) score (1-5 scale algorithm used to help determine acuity and resources needed with 1 being most severe) of 4. At 5:04 PM intravenous (IV) fluids were started, and patient #2 was monitored "in triage hallway." Patient #2 was discharged 11/09/2021 at 9:21 PM. There was no ED RN focused assessment documented.

Patient #4's medical record revealed Patient #4 was a 65-year-old who presented to the ED 11/10/2021 at 5:49 PM with the chief complaint of abdominal pain. Patient #4 was triaged at 6:49 PM with an ESI score of 3 and taken back to an ED room at 8:59 PM. ED RN focused cardiac and gastrointestinal nursing assessment was completed at 12:00 midnight (3 hours after being roomed in the ED). There was no ED RN pain assessment documented. Patient #4 was discharged 11/11/2021 at 4:19 AM.

Patient #5's medical record revealed Patient #5 was a 68-year-old who presented to the ED 11/16/2021 at 5:05 PM with the chief complaint of chest discomfort and a history of coronary artery disease. Patient #5 was triaged at 5:26 PM with an ESI of 3, roomed as an observation status patient in the ED at 10:20 PM with a provider order for admission to Medical Surgical bed with Telemetry. There were no pain assessments documented. Patient #5 was discharge from the Emergency Department 11/17/2021 at 6:29 PM.

Patient #6's medical record revealed Patient #6 was a 31-year-old who presented to the Emergency Department 11/06/2021 at 6:43 AM with the chief complaint of abdominal pain. Patient #6 was triaged and taken back to an ED room at 6:45 AM with an ESI score of 3. At 6:46 AM Patient #6 rated her/his abdominal pain as 6 out of 10. At 9:04 AM Toradol intravenous medication (for moderate to severe pain) was given. At 9:08 AM (2 hours and 25 minutes after patient #6 was roomed) a RN focused gastrointestinal assessment was completed. Patient #6 was treated and discharged 11/06/2021 at 12:23 PM. There was no ED RN reassessment of pain documented.

Patient #9's medical record revealed Patient #9 was a 39-year-old who presented to the ED 10/08/2021 at 4:20 AM with the chief complaint of worsening chronic pain and abdominal cramping. Patient #9 was triaged and taken back to an ED room at 5:00 AM with an ESI score of 3 and pain score of 9 of 10 (no location of the pain documented). At 5:50 AM Patient #9 was given Dilaudid 1 mg (opioid analgesic) intravenously (IV). Pain was reassessed as a 4 out of 10 at 7:00 AM (greater than 30 minutes after administration of IV pain medication) and inpatient admission orders were given 10/08/2021 at 2:43 PM. Patient #9 was transferred to the Medical Surgical floor 10/08/2021 at 5:17 PM with no pain reassessments documented 10/08/2021 between 7:00 AM and 5:17 PM. There was no ED RN focused nursing assessment documented. Patient #9 was discharged home 10/10/2021.

Patient #11's medical record revealed Patient #11 was a 70-year-old who presented to the ED 11/05/2021 at 9:09 AM with the chief complaint of shortness of breath. Patient #11 was triaged at 10:12 AM with an ESI score of 2 and taken back to an ED room at 10:17 AM. At 10:13 AM vital signs were blood pressure 87/57 (low), respiratory rate 28 (high). At 11:36 CT resulted with acute saddle pulmonary embolism with acute cor pulmonale (blood clot in the lungs). Repeat vital signs were not documented until 11:45 AM. Patient #11 was transferred to Interventional Radiology (IR) at 12:53 PM for a thrombectomy (surgery to remove blood clot). Patient #11 expired 11/05/2021 at 3:15 PM from a cardiac arrest. There was no ED RN focused gastrointestinal, cardiac, or pulmonary nursing assessment documented.

On 11/18/2021 at 8:35 AM during interview with Trauma Coordinator J and ED Manager C, ED manager C, Trauma Coordinator J confirmed, at a minimum, an ED RN is responsible to do "at least" a focused assessment on all ED patients.

On 11/18/2021 at 3:13 PM at completion of medical record review with Quality & Patient Safety Coordinator D, Coordinator D confirmed focused ED RN nursing assessments, and pain assessments and reassessments and were not found in Patient #4, #5, #6, #9 and #11's medical records stating "no, we didn't find any additional documentation."