HospitalInspections.org

Based on policy review, medical record review, and staff interviews the facility staff failed to assess and reassess a patient's pain in the emergency department (ED) for 2 of 11 patients (Patient #2, and Patient #4), failed to reassess patient's vital signs in the ED for 4 of 11 patients (Patient #1, #2, #13, #19), failed to document a nursing assessment on patients in the ED for 3 of 10 patients (Patient #2, #4, and #20) and failed to administer a medication per physician order in the ED for 1 of 11 patients (Patient #2).

The findings included:

1. Review on 10/27/2020 on a policy titled "Pain Management" last revised 11/2019 revealed "...For the ED: Initial patient history will include screening for the presence of pain. If pain is present, an appropriate pain assessment tool will be used to elicit intensity. If the patient is able to verbally communicate, other factors associated with the pain will be assessed such as location, laterality... Reassessment will be performed after an intervention and will include, at a minimum, the intensity of the pain. If the patient appears to be sleeping, reassessment will be limited to respiratory rate..."

a. Closed medical record review on 10/27/2020 of Patient #2 revealed a 83-year-old female who arrived at the ED on 08/12/2020 at 1957 with a chief complaint of chills and abdominal pain. Review of the triage note revealed "...pt (patient) c/o (complains of) intermittent chills since last night and c/o discomfort in upper abdomen. denies n/v (nausea/vomiting) cough, denies contact with sick people, denies CP/SOB. (chest pain/shortness of breath) hx HTN (hypertension-high blood pressure)..." Review of the triage pain assessment revealed "...Pain Present Yes..." Review revealed Patient #2 was discharged home on 08/13/2020 at 0853. Review failed to reveal an appropriate pain assessment tool to elicit intensity of pain for Patient #2.

Request on 10/28/2020 to interview the nurse who took care of Patient #2 revealed she was unavailable.

Interview on 10/28/2020 at 1045 with the Director of the ED revealed pain assessments should be done at triage and after an intervention.

b. Closed medical record review on 10/28/2020 of Patient #4 revealed a 26-year-old female who arrived at the ED on 08/12/2020 at 2350 with a chief complaint of headache. Review of the triage notes revealed "...pt c/o headache since Sunday. says pain is in her forehead and radiates down her face. denies numbness/tingling. hx (history) migraines. took advil at home with no relief..." Review of a triage pain assessment revealed her pain was 7 out of 10 (0-10 pain scale where 0 is no pain and 10 is the worst pain) in her head. Review revealed at 0049 on 08/13/2020 Patient #4 was given Reglan (anti-nausea medication) 5 mg (milligrams) and 12.5mg of Benadryl (anti-histamine medication). Review failed to reveal a pain assessment after the medication administration. Review revealed Patient #4 was discharged on 08/13/2020 at 0329.

Interview on 10/28/2020 at 1345 with RN #2 (Registered Nurse) revealed she administered the medication to Patient #4. Interview revealed the medication combination that was given was often called a "headache cocktail" to treat headaches. Interview revealed RN #2 stated she was most likely tasking when she gave Patient #4 the medication which meant she was trying to complete tasks for each patient in the triage area. Interview confirmed Patient #4's pain was not reassessed. Interview revealed pain should be assessed at triage and then after an intervention.

Interview on 10/28/2020 at 1045 with the Director of the ED revealed pain assessment should be done at triage and after an intervention.

2. Review on 10/27/2020 of a policy titled "Assessment-Reassessment of the Emergency Department Patient" last revised 11/2019 revealed "...2. Vital signs will be reassessed every 4 hours or more frequently based on patient condition...3. Reassessment of vital signs will be documented within one hour of admission, discharge or transfer..."

a. Closed medical record review on 10/27/2020 of Patient #1 revealed a 63-year-old male who arrived at the ED on 08/12/2020 at 1812 with a chief complaint of chest pain. Review revealed vital signs obtained at 1830 during triage were temperature 98.0 degrees Fahrenheit, heart rate 68, respirations 24, blood pressure 164/93, and oxygen saturation 100% on room air. Review revealed Patient #1 "Left Without Being Seen" on 08/13/2020 at 0118 (6 hours and 48 minutes after the initial set of vital signs). Review failed to reveal any other vital signs documented for Patient #1.

Interview on 10/28/2020 at 1300 with RN #1 revealed she triaged Patient #1. Interview revealed normally when patients were waiting in the lobby the healthcare technician would get vital signs every four hours for patients. Interview confirmed Patient #1 only had one set of vital signs.

Interview on 10/28/2020 at 1045 with the Director of the ED revealed it was the responsibility of the triage nurse to ensure vital signs were obtained every four hours for patients in the lobby.

b. Closed medical record review on 10/27/2020 of Patient #2 revealed a 83-year-old female who arrived at the ED on 08/12/2020 at 1957 with a chief complaint of chills and abdominal pain. Review revealed vital signs obtained at 2142 during triage were temperature 98.4 degrees Fahrenheit, heart rate 88, respirations 16, blood pressure 188/97, and oxygen saturation 96% on room air. Review revealed vital signs were not obtained again until 08/13/2020 at 0700 (9 hours and 19 minutes after the initial set of vital signs). Review revealed Patient #2 was discharged at 0915 on 08/13/2020.

Request on 10/28/2020 to interview the nurse who took care of Patient #2 revealed she was unavailable.

Interview on 10/28/2020 at 1045 with the Director of the ED revealed vital signs should be obtained every four hours per policy.

c. Closed medical review on 10/27/2020 of Patient #13 revealed a 34-year-old male who arrived at the ED on 10/26/2020 at 1048 with a chief complaint of shortness of breath. Review revealed vital signs obtained at 1106 during triage were temperature 98.0, heart rate 62, respirations 17, blood pressure 133/73, and oxygen saturation 99% on room air. Review revealed vital signs were not obtained again until 1616 (5 hours and 12 minutes after the initial set of vital signs). Review revealed Patient #13 was discharged at 1930.

Interview on 10/28/2020 at 1045 with the Director of the ED revealed vital signs should be obtained every four hours per policy.

d. Closed medical record review on 10/29/2020 of Patient #19 revealed a 53-year-old male who arrived to the ED on 07/31/2020 at 1904 with a chief complaint of low hemoglobin (blood count). Review revealed vital signs obtained at 2005 during triage were temperature 98.7, heart rate 93, respirations 18, blood pressure 145/73, and oxygen saturation 99% on room air. Review revealed vital signs were not obtained again until 08/01/2020 at 0645 (10 hours 40 minutes). Review revealed Patient #19 was discharged at 0811.

Interview on 10/28/2020 at 1045 with the Director of the ED revealed vital signs should be obtained every four hours per policy.

3. Review on 10/27/2020 of a policy titled "Assessment-Reassessment of the Emergency Department Patient" last revised 11/2019 revealed "...B. Initial Assessment...3. Assessment parameters, as appropriate, to the Reason for Visit. a. Documentation is performed by exception based on defined limits criteria... Findings outside of WDL (within defined limits) criteria will be documented in the appropriate body system. If an injury or illness is isolated to a single body system, only the pertinent contributory body systems must be assessed...C. Reassessment 1. Reassessment findings are documented by exception based on defined limits criteria...at least every four hours, or more frequently with change in condition. Responses to treatment, therapy and diagnostic procedures will be documented..."

a. Closed medical record review on 10/27/2020 of Patient #2 revealed a 83-year-old female who arrived at the ED on 08/12/2020 at 1957 with a chief complaint of chills and abdominal pain. Review of the triage note revealed "...pt c/o intermittent chills since last night and c/o discomfort in upper abdomen. denies n/v, cough, denies contact with sick people, denies CP/SOB. hx HTN..." Review revealed Patient #2 was discharged on 08/13/2020 at 0853. Review failed to reveal a nursing assessment documented during Patient #2's ED visit.

Interview on 10/28/2020 at 1045 with the Director of the ED revealed there should be a focused nursing assessment for each patient related to the patient's chief complaint. Interview confirmed there was no focused nursing assessment for Patient #2.

b. Closed medical record review on 10/28/2020 of Patient #4 revealed a 26-year-old female who arrived at the ED on 08/12/2020 at 2350 with a chief complaint of a headache. Review of the triage note revealed "...pt c/o headache since Sunday. says pain is in her forehead and radiates down her face. denies numbness/tingling, hx migraines. took advil at home with no relief..." Review revealed Patient #4 was discharged on 08/13/220 at 0329. Review failed to reveal a nursing assessment documented during Patient #4's ED visit.

Interview on 10/28/2020 at 1045 with the Director of the ED revealed there should be a focused nursing assessment for each patient related to the patient's chief complaint. Interview confirmed there was no focused nursing assessment for Patient #4.

c. Closed medical record review on 10/29/2020 of Patient #20 revealed a 55-year-old male who arrived to the ED on 07/17/2020 at 1646 with a chief complaint of high potassium. Review of the triage note revealed "...pt sent by PCP (primary care physician) for K+ (potassium) of 6.2.. denies any CP. (chest pain) endorses intermittent numbness/tingling in bilateral arms. SOB on exertion. hx 2 cardiac stents..." Review revealed Patient #20 was discharged at 2025. Review failed to reveal a nursing assessment documented during Patient #20's ED visit.

Interview on 10/28/2020 at 1045 with the Director of the ED revealed there should be a focused nursing assessment for each patient related to the patient's chief complaint. Interview confirmed there was no focused nursing assessment for Patient #20.

4. Closed medical record review on 10/27/2020 of Patient #2 revealed an 83-year-old female who arrived at the ED on 08/12/2020 at 1957 with a chief complaint of chills and abdominal pain. Review of the triage note revealed "...pt c/o intermittent chills since last night and c/o discomfort in upper abdomen. denies n/v cough, denies contact with sick people, denies CP/SOB. hx HTN..." Review revealed a urinalysis was ordered and resulted at on 08/13/2020 at 0820 showing a urinary tract infection (UTI). Review revealed Keflex (antibiotic) 500mg PO (by mouth) was ordered on 08/13/2020 at 0851. Review revealed Patient #2 was discharged at 0915. Review failed to reveal the Keflex being administered prior to Patient #2's discharge.

Interview on 10/28/2020 at 1420 with PA #1 (Physician Assistant) revealed she recalled Patient #2. Interview revealed she had ordered Patient #2 to get Keflex in the ED and prescribed her Keflex to go home with because Patient #2 had a UTI. Interview revealed PA #1 ordered for Patient #2 to receive her first dose of Keflex in the ED because she didn't know if there would be a delay in Patient #2 getting to the pharmacy after discharge. Interview revealed PA #1 was not aware that Patient #2 did not get Keflex prior to her discharge.

Interview on 10/28/2020 at 1530 with RN #3 revealed she did not recall Patient #2. Interview revealed when medications were ordered RN #3 followed the orders and administered the medication. Interview revealed she did not know why an ordered medication would not have been given.
NC00169029, NC00168445, NC00161201