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Based on interview and record review, the facility failed to ensure emergency services were appropriate to the scope of services offered for 2 (Patient #'s 7 & #8) of 10 patients reviewed.


The facility failed to:

A. Ensure nursing staff documented consistent follow up assessments after administration of medications. The nursing staff failed to document pain re-assessments after administration of pain medication and discharge.

B. Ensure ED nursing staff documented accurate respiratory assessments on 1 of 10 sampled patients (Patient #8). The facility failed to ensure patients on non-invasive ventilation (C-PAP and BI-PAP) had complete physician orders and nursing documented which type of ventilation was being used after a decline in respiratory condition. The facility failed to ensure respiratory medications were administered timely on Patient #8.

C. Ensure the staff consistently documented vital signs after the administration of medications and at discharge.



Findings include:


PATIENT # 7

The triage notes on 6-3-2019 at 6:20 a.m. listed a chief complaint as vomiting and stomach pain. Patient #7 stated, "Been vomiting since yesterday. Too many times to count."

The Acuity level was 3 (Urgent).

Vital signs at 6:19 a.m. were Blood Pressure 139/112, pulse 64, respirations 20, Oxygen saturation 100%, Temperature 97.8. Pain was 9 on a 1-10 scale.

The ED (Emergency Department) provider assessment was documented at 6:29 am. The chief complaint was listed as vomiting and stomach pain. The HPI (History Present Illness) listed vomiting reported by the patient. Quality of pain was listed as worsening for 2 days, and severe. The associated symptoms were listed as abdominal pain, decreased appetite, nausea.
The physical exam documented by the physician listed diminished bowel sounds and epigastric tenderness.


Review of the Physician orders revealed the following:

Medications:
7:01 a.m. Ketorolac IV (Intravenous) - 30 mg IV push once. There was no indication listed on the order. The order was listed as a NOW order.
7:41 am - Morphine IV (Intravenous) 4 mg- IV push once. The was no indication listed on the order. The order was listed as a NOW order.

7:01 a.m. - Ondansetron IV 8 mg - IV push once. There was no indication listed on the order. The order was listed as a NOW order.

7:42 a.m. Phenergan IV 25 mg IV - IV push once. There was no indication listed on the order. The order was listed as a NOW order.

11:37 a.m. - Ondansetron 4 mg - IV push once. There was no indication listed on the order. The order was listed as a NOW order.


Review of the Medication Administration Record revealed the following:

Ketorolac (Nonsteroidal anti-inflammatory drug used for moderately severe acute pain) 30 mg given IV at 7:01 a.m. by Staff #13. There was no pain level documented prior to administration. There was no pain re-assessment documented after administration of the pain medication.

Morphine (Pain Medication) 4 mg given IV at 7:41 a.m. by staff #12. There was no pain level documented prior to administration. There was no pain re-assessment documented after administration of the pain medication.

Ondansetron (Anti-Nausea mediation) 8 mg given IV at 7:01 a.m. by staff #13. There was no follow up assessment documented in the chart after the medication was given to indicate the patient's response to the medication.

Phenergan (Anti-Nausea medication) 25 mg given IV at 7:42 a.m. by staff #12. There was no follow up assessment documented in the chart after the medication was given to indicate the patient's response to the medication.

Ondansetron (Anti-Nausea medication) 4 mg given IV at 11:37 a.m. by staff #12. There was no follow up assessment documented in the chart after the medication was given to indicate the patient's response to the medication. There were no vital signs taken after the medication was given nor prior to discharge.



Review of the Discharge Visit Summary revealed the following:

The vital signs documented on the discharge summary were listed at 11:00 am; almost 2 hours prior to discharge. The vital signs were blood pressure 141/100, pulse 98, oxygen saturation 100 %. There was no pain level or temperature documented. The pain level listed on the discharge level was 9 on a 1/10 scale. The pain level was documented at 6:19 a.m. There was no pain level re-assessment documented during the ED stay.



Review of training provided by the facility for nursing revealed the following:


An attestation signed by Staff #2 on 5-28-2019 revealed the following:

I have read, and I understand the ED nursing staff in-service information on documentation of:
Vital signs, pain levels, assessment/reassessment, medication administration, indications of treatments, discharge, education.

An attestation signed by Staff # 13 on 5-30-2019 revealed the following:

I have read, and I understand the ED nursing staff in-service information on documentation of:
Vital signs, pain levels, assessment/reassessment, medication administration, indications of treatments, discharge, education.


An attestation signed by Staff # 14 on 5-30-2019 revealed the following:

I have read, and I understand the ED nursing staff in-service information on documentation of:
Vital signs, pain levels, assessment/reassessment, medication administration, indications of treatments, discharge, education.



Review of the facility Policy Titled, "ASSESSMENT AND REASSESSMENT: dated July 15,2018 revealed the following:

"A.2. Reassessment

a. Reassessment is a component of the patient plan of care and is conducted at key determinate events as well as throughout the care continuum. Reassessment is the evaluation of patient response to treatment and care to determine the appropriateness and effectiveness of care decisions.

...D.2. Reassessment: Reassessment determines the patient's response to care and treatment. Patient reassessment is ongoing and may be triggered at key decisions points and at any interval specified by the clinical disciplines directly involved in providing patient treatment and/or care. Each patient is to be reassessed according to discipline-specific guidelines. Patient reassessment will occur at specified, regular intervals related to:

a. patient treatment/procedures

b. patient response to treatment/procedures

c. significant change in the patient condition

d. significant change in the patient diagnosis

e. discharge planning where appropriate in the scope of care of the applicable department


.... F.2.c. The reassessment process includes, but is not limited to review of the following parameters as needed depending on changes in the patient's progress:

1. Physical: head to toe assessment

2. psychosocial

3. wounds, dressings, invasive lines

4. activity

5. patient care needs

6. response to treatment

7. skin integrity/pressure ulcers

8. nutritional/malnutrition status

9. functional status

10. pain - location, type, intensity, change

11. fall risk

12. aspiration risk

13. DVT/VTE risk

14. Other risk assessments as needed if the patient's status changes"



Review of a facility policy titled, "Patient Assessment/Reassessment" with an effective date of July 15, 20018 revealed the following:

" ...C. Patients with an ESI triage level of 1,2, or 3 will require vital signs and reassessment more frequently, based on the patient's clinical condition, and medical treatments and interventions performed. At a minimal vital signs every 2 hour, more frequently as condition dictates.

D. An assessment including vital signs should be completed within 30 minutes of discharge from the ED for all patients."




10135

Patient #8

Review of the record of Patient #8 revealed he was a 92-year-old male who presented to the Emergency department (ED) on 06/03/2019 for shortness of breath.



Review of a triage assessment and an initial nursing assessment timed 11:00 a.m. and by the same nurse, revealed the following:

"Breathing: respirations regular rate and rhythm; unlabored"

"Respiratory supplemental oxygen:(CPAP); labored; accessory muscle use; grunting; RUL; diminished; RLL: diminished; LUL: diminished; LLL: diminished."
There was a discrepancy in the assessments.


Review of the physician's medical screening at 12:20 p.m., revealed Patient #8 was given the diagnoses of sepsis and congestive heart failure.


Review of ED vital sign flow sheets revealed Patient #8 was on a CPAP (continuous positive airway pressure) at 10:50 a.m., 11:00 a.m.., and 11:55 a.m. Patient #8's oxygen saturation ranged from 92 -96 percent during that timeframe.
There was no order on the chart to continue on the CPAP ventilation.

Review of a physician's order at 11:56 a.m., revealed Patient #8 was to get the respiratory medication Albuterol "once" and "now."

From 12:25 p.m-2:25 p.m., Patient #8 was documented as being on oxygen 2-3 Liters per nasal cannula with an oxygen saturation ranging from 92-94 percent.

Review of a physician's orders at 2:47 p.m., revealed staff were to initiate a BIPAP (Bi-level positive airway pressure) ventilation. The settings were not included in the order.


According to respiratory documentation at 2:50 p.m., Patient #8 was changed from CPAP to a BIPAP with settings at 10/6, 16, 40%. The neb treatment (Albuterol) was administered in line with the BIPAP. The medication was given almost three hours after it was ordered.

Review of a facility's policy dated 07/15/2019 named "STAT, NOW AND ROUTINE ORDERING" revealed the following:

"..All NOW orders are to be done within 60 minutes.."



According to nursing notes at 3:00 p.m., there was documentation that Patient #8's oxygen saturation had dropped to 90 percent and there was no documentation of an assessment of oxygen therapy nor BIPAP usage.


During an interview on 06/10/2019 after 1:00 p.m., Staff #11 confirmed the assessments and the administration of the respiratory medication. Staff #11 said Patient #8 was on a BIPAP during the ED stay and nursing had written CPAP in error. Staff #11 said that they only had BiPAP machines at the ED. Staff #11 said he did not know if their equipment converted over to CPAP. After surveyor questioning, Staff #11 said he asked respiratory about the equipment and was told that it could be switched over to CPAP.