HospitalInspections.org

Based on observations during tour, hospital policy review, medical record review and patient and staff interviews, the nursing staff failed to: assess/reassess patient per hospital policy for 1 of 5 sampled records reviewed and ensure patients have access to and respond to call bells for 3 of 5 observations during tour.

The findings include:

A. Review of hospital policy titled "Nursing Documentation Standards for the ED" Date this version effective May 2016 revealed "... Nursing Documentation throughout the Patient Encounter 1. Primary/Clinical Nurse should document: ...b. Patient Rounds... c. Pain Assessment... *If pain score is 4 or greater - document an intervention. *Interventions can be non-pharmacological. *Reassess pain level and document reassessment within 1 hour of intervention. ... 4. Evidence of Re-evaluation throughout ED encounter: a. Vital Signs ...*Acuity/ESI (Emergency Severity Index) level 1 & 2 the minimum is every 2 hours. ...b. Nursing Assessment/Reassessment *Focused patient reassessments should be documented every 4 hours for all patients. ...Nursing Documentation for Patient Disposition - Admission/Transfer/Discharge ...2. Discharge Summary ...*Vital signs and pain score at time of discharge ...Acuity/ESI 1, 2 & 3 within 1 hour of discharge..."

Review of medical record on 02/07/2017 for Patient #7 revealed a 54 year old male that presented to the Emergency Department on 12/10/2016 at 1547 with a chief complaint of falling 20 feet to the grassy ground from a tree stand and discharged on 12/11/2016 at 0059. Review of record revealed patient arrived via air transport at 1547 and was immediately placed in a trauma room. Review revealed patient was fully immobilized and on cardiac monitor upon arrival. Record revealed patient was assessed for airway, breathing and circulation by nursing staff at 1548 with a Glasgow Coma Scale (level of consciousness after a traumatic injury) of 15 (best response). Secondary head to toe assessment documented at 1549 revealed all systems negative except neurological exam. Neurological exam revealed patient was log rolled on backboard and spinal area was assessed prior to removing backboard. Assessment revealed positive lower thoracic tenderness with no deformity. Review revealed vital signs assessed at 1548 blood pressure 173/96, temperature 97.9, heart rate 81, respiratory rate 17 and oxygen saturation 100% on 2 liters/minute via nasal cannula. Nursing documentation revealed patient was seen by a provider at 1549. Review revealed patient received 300 milliters of Normal Saline and Fentanyl (pain medication) 200 micrograms prior to arrival in the Emergency Department.

Record review revealed physician orders dated 12/10/2016 at 1550 for cardiac monitoring, oxygen saturation continuous monitoring, vital signs, Nothing by mouth - Strict, trauma surgery consult, strict intake and output, intravenous insertions x 2, type and screen, blood for numerous laboratory tests, urinalysis with culture, urine drug screen, portable chest x-ray and portable pelvis x-ray. Documentation revealed trauma surgery consult ordered at 1550 and notified at 1551. Nursing notes at 1552 revealed "Patient states that lower extremities feel like they are asleep. Review of record revealed Medical Screening Exam was completed by a provider at 1552. Physician provider notes revealed Initial Impression and Assessment "54-year-old male presents as yellow trauma with a fall from 20 feet onto his buttocks, reporting thoracic and lumbar spinal pain, able to crawl from the scene, but now with tingling to his extremities or on exam he does have notable tenderness on his lower thoracic to lumbar spine with no appreciable deformity. No other external signs of injury. Hemodynamically stable. Will obtain whole-body CT imaging except for head CT, anticipating neurosurgical consult."

Pain assessment completed at 1555 revealed back pain rated "10" (10 worst, 0 no pain) with Fentanyl 50 micrograms given intravenously for pain. Review revealed vital signs documented on 12/10/2016 at 1559 heart rate 71, respirations 10, blood pressure 153/101 and oxygen saturation 100%. Pain assessment completed at 1626 revealed back pain rated "5". Nursing documentation revealed vital signs at 1627 heart rate 75, respirations 17, blood pressure 156/96 and oxygen saturation 100% on room air. Patient #7 triaged as an acuity level 2 and placed in the acute unit of the Emergency Department 1627. Nursing documentation at 1736 revealed Fentanyl 50 micrograms given intravenously for pain. Review of record revealed no available documentation of a pain assessment prior to or after administering Fentanyl 50 micrograms at 1736.

Review of nursing notes revealed vital signs documented at 1902 heart rate 86, respirations, 16, blood pressure 165/87 and oxygen saturation 97% (2 hours and 35 minutes after last vital signs taken). Review of physician orders at 1935 revealed an order for Morphine (pain medication) 4 milligrams intravenous. Nursing notes revealed Morphine 4 milligrams administered at 1940. Pain assessment documented at 1955 revealed pain rated "2". Vitals signs documented at 2106 heart rate 85, respirations 16, blood pressure 166/88 and oxygen saturation 97% on room air. Further review of record revealed no available documentation of vital signs after 12/10/2016 at 2106. Review of physician orders at 2225 revealed an order for Percocet (pain medication) 5-325 milligrams, one tablet by mouth. Documentation revealed Percocet 5 milligrams administered by mouth at 2237 by nursing staff. Review of record revealed no available documentation of a pain assessment prior to or after administering Percocet 5 milligrams at 2237.

Physician orders at 0022 revealed an order for Percocet 5-325 milligrams, one tablet, by mouth and Zofran (nausea medication) 4 milligram disintegrating tablet. Review of nursing documentation revealed Percocet 5 milligrams orally given at 0032 and Zofran 4 milligrams given at 0034. Review of record revealed no available documentation of a pain/nausea assessment/reassessment prior to or after Percocet 5 milligrams administered at 0032 and Zofran 4 milligrams administered at 0034.

Nursing documentation at 0056 revealed intravenous lines removed. Further review revealed documentation at 0058 of discharge instructions reviewed, follow-up care reviewed, medications discussed and patient verbalized understanding of instructions. Documentation revealed nursing staff assisted patient to car via wheelchair with family. Review of record revealed no available documentation of vitals signs within 1 hour of discharge.

Interview on 02/09/2017 at 0842 with primary care registered nurse revealed she was the nurse that took care of patient while in trauma room and after he was moved to regular Emergency Department room. Interview revealed she was in and out of the room throughout her shift. Interview revealed she was notified that patient's wife had come out of the room and requested pain medication. Interview revealed orders were obtained for intravenous pain medication and later for by mouth pain medication. Interview revealed she liked to administer intravenous pain medication to provide quick relief and follow with by mouth pain medication to sustain the pain relief. Interview revealed the patient should have had a call bell and that she usually either ties the single push button call bell to the stretcher side rail or gives the television/call bell to the patient to place in the bed. Interview revealed she usually obtains vital signs within one hour of discharge or at discharge. Interview revealed the patient was on a monitor and vital signs were being documented at least every 4 hours. Interview revealed pain re-assessments should be documented in the pain assessment field in the medical record with 1 hour of intervention. Interview revealed she always assesses pain before she gives pain medications, but is "not always 100% on charting pain level" in medical record.

Interview on 02/07/2017 at 1500 with Emergency nurse supervisor revealed vital signs are re-assessed at least every 30 minutes if within normal limits while in the trauma room and more often if out of range (abnormal). Temperatures are re-assessed every 30 minutes only if abnormal. Any abnormal vital signs are re-assessed every 15 minutes. Interview revealed vital signs are re-assessed based on patient's acuity level and are usually obtained every 4 hours after patient is moved from trauma room to and Emergency Department room.

B. Review of hospital policy titled "Nursing Documentation Standards for the ED (Emergency Department)" Date this version effective May 2016 revealed "... Nursing Documentation throughout the Patient Encounter 1. Primary/Clinical Nurse should document: ...b. Patient Rounds *Safety Measures/Safe Environment, when placed in room... 4. Evidence of Re-evaluation throughout ED encounter: ... b. Nursing Assessment/Reassessment ...*Patient Rounding should occur every 2 hours on all ED patients..."

Review of hospital policy titled "Fall Precautions" Date this Version Effective July 2016 revealed "Universal Falls Interventions Universal fall precautions should be implemented for all patients regardless of fall risk score: *Familiarize the patient to the environment *Have the patient 'teach back' use of the call bell and light use. *Keep the call bell light within reach at all times ...*Ensure that call light, urinal, bedpan, telephone, drinking water, and patient's personal items (cell phone, lip balm, etc.) are within easy reach..."

Review of medical record on 02/07/2017 for Patient #7 revealed a 54 year old male that presented to the Emergency Department on 12/10/2016 at 1547 with a chief complaint of falling 20 feet to the grassy ground from a tree stand and discharged on 12/11/2016 at 0059. Review of record revealed patient arrived via air transport at 1547 and was immediately placed in a trauma room. Nursing notes revealed patient rounds were conducted at 1709, 1758, 1859, 2006, 2214 and 2305. Pain, toileting, personal belongings, plan of care, call bell in reach and bed position low needs were assessed during patient rounds.

Observations during tour of the Emergency Department on 02/08/2017 between 1430 and 1515 revealed 3 of 5 patients, rooms 23, 24 and 25 observed did not have a call bell within reach. Observations revealed the call bells were hanging over the oxygen flow meter on the wall at the head of the bed and were not available to the patient. Observation revealed 4 nurses sitting in the nurses' station across from Room 23, 24 and 25. Observation revealed nursing assistant watching the behavioral health rooms monitor across the hall from room 25. Observation of call bell activated in the bathroom near room 7 revealed a volunteer came to the end of the nursing station, looked at the flashing light above the bathroom door, but did not approach the bathroom to assist. Observation revealed the call bell in the bathroom did not have voice capabilities (telecom function), so the staff would need to respond to the room to identify the problem.

Interview during tour on 02/08/2017 at 1430 with patient in Room 25 revealed "I have been here since 8:30 this morning and have not had a call bell since I got here. I have called out to nurses, but no one answers. I do need a nurse to help me get on the bedpan."

Observation of Room 25 after obtaining nursing assistance for the patient to use the bedpan revealed the call bell had been moved from the oxygen flow meter and was hanging on the intravenous pump pole, still out of reach of the patient.

Interview on 02/08/2017 at 1455 revealed the call bells in rooms 1-25 do not have telecom capabilities. Interview revealed if a call bell is activated in rooms 1-25, someone would need to go to the room to determine the problem. Interview revealed when a patient activates the call bell system, an alarm goes to the secretary desk and the secretary will page staff overhead. Interview confirmed the call bells in rooms 23, 24 and 25 were not in reach of the patient and were not available for patient use.

Interview on 02/08/2017 at 1545 revealed the emergency department staff are expected to give the call bell to every patient placed in a bed in a room. Interview revealed the nursing staff did not follow the hospital policy for call bells. Interview confirmed the findings.

NC00123544, NC00124911