HospitalInspections.org

Based on review of medical records, review of policy and procedure and interview with staff, in 7 of 10 emergency room medical records (ERMR) (1, 4, 5, 6, 7, 9 and 10 ) the facility failed to ensure pain assessments and reassessments are completed per policy.

Findings include:

Facility policy titled Emergency Room Record, Documentation does not include assessment of pain.
Facility policy titled Pain Assessment states "Pain will be assessed in a manner that will give staff a clear image of the patient's condition allowing for timely and effective treatment." Under #1. "Consider the patient's response to questions regarding pain...2. Ask patient to rank the pain on a scale of 0-10, with 0 denoting lack of pain and 10 denoting the worst pain level...Document response. #. Observe the patient for non-verbal responses to pain...4. Guide patient in finding techniques to reduce pain/enhance analgesic effect...5. Evaluate patient response to Analgesics and other relief methods and document current verbalized pain level and observations."

Facility policy titled Emergency Department Patient, Reassessment of states "Each Emergency Department patient is reassessed, including physical, social and psychological evaluation at least every 30 minutes or sooner related to the patient's course of treatment...1. Reassessment of each Emergency Department patient is done at least every thirty minutes, for any change in patient's condition, and at time of discharge."

Patient (Pt) #1's ERMR review by surveyor 18816 on 4/7/10 at 9:00 AM revealed she arrived in the ER at 6:15 PM with a complaint of pain rated 6-7. Pt #1 had been given a pain medication, Fentanyl, upon arrival, there is no reassessment of pain level until 7:40 PM. Pt #1 was given another pain medication, Dilaudid, at 8:15 PM, there is no reassessment of pain other than the note at 8:45 PM "(no change) in leg pain..." and at 10:25 PM "cont. (continue) to have knee pain.". This is confirmed in interview with Quality Improvement Coordinator (QIC) on 4/7/10 at 2:15 PM.

Pt #4's ERMR review by surveyor 18816 on 4/7/10 at 11:35 AM revealed she arrived in the ER on 1/2/10 at 11:29 AM with a complaint of a headache rated 2, after a fall during a sledding accident 2 days previous. The pt was not taken back to an ER room until 2:30 PM. There is no documentation in the record of Pt #4's status during the 3 hour wait in the waiting room. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #5's ERMR review by surveyor 18816 on 4/7/10 at 12:00 PM revealed he arrived in the ER on 11/6/09 at about 5:25 PM, with a complaint of sore throat rated 2. Pt #5 was taken back to the ER room at 6:15 PM, there is no documentation of the patient's status during the 45 minute wait, there is no other documentation of Pt #5's pain level. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #6's ERMR review by surveyor 18816 on 4/7/10 at 12:06 PM revealed he arrived in the ER on 9/1/09 at 12:05 PM with a complaint of pain in his right leg. There is no documentation his pain rating. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #7's ERMR review by surveyor 18816 on 4/7/10 at 12:25 PM revealed he arrived in the ER on 3/4/10 at 11:09 PM with a complaint of pain in his leg rated 5-6. There is no other documentation of his pain rating to discharge at 12:40 AM on 3/5/10. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #9's ERMR review by surveyor 18816 on 4/7/10 at 12:43 PM revealed he arrived in the ER on 11/11/09 at 1:35 AM with a complaint of bilateral knee pain rated 9. Pt #9 was given pain medications Vicodin and Toradol at 2:55 AM and 2:57 AM respectively. There is no other documentation of his pain rating to discharge at 3:30 AM. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #10's ERMR review by surveyor 18816 on 4/7/10 at 12:55 PM revealed he arrived in the ER on 9/8/09 at about 5:55 PM with complaint of pain after a fall. There is no documentation of pain rating in the record. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Based on review of medical records, review of policy and procedure and interview with staff, in 8 of 10 emergency room medical records (ERMR) (#1, 2, 4, 6, 7, 8, 9 and 10), the facility failed to ensure all orders are written with a date and time, and/or verbal, standing or telephone orders are authenticated by the Medical Doctor (MD) with a signature, date and time.Findings include:

Facility policy titled Emergency Room Documentation states under #35. "Specific MD orders." The policy does not include date and times of orders, or MD authenticating verbal, standing or telephone orders.

Patient (Pt) #1's ERMR review by surveyor 18816 on 4/7/10 at 9:00 AM revealed there are lab, X-ray, oxygen, telemetry orders written without a date and time. This is confirmed in interview with Quality Improvement Coordinator (QIC) G on 4/7/10 at 2:15 PM.

Pt #2's ERMR by surveyor 18816 on 4/7/10 at 12:30 PM revealed there are lab and X-ray orders written without a date and time. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #4's ERMR by surveyor 18816 on 4/7/10 at 12:30 PM revealed there are X-ray orders written without a date and time. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #6's ERMR by surveyor 18816 on 4/7/10 at 12:06 PM revealed there are X-ray orders written without a date and time. There is verbal order for Magnesium Citrate that is not authenticated by the MD with a date and time. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #7's ERMR by surveyor 18816 on 4/7/10 at 12:25 PM revealed there are X-ray orders written without a date and time. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #8's ERMR by surveyor 18816 on 4/7/10 at 12:36 PM revealed there are lab and X-ray orders written without a date and time. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #9's ERMR by surveyor 18816 on 4/7/10 at 12:43 PM revealed there are X-ray orders written without a date and time. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt # 10's ERMR by surveyor 18816 on 4/7/10 at 12:55 PM revealed there are X-ray orders written without a date and time. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Based on review of medical records, review of policy and procedures and interview with staff, in 8 of 10 medical records (MR) (#1, 3, 4, 6, 7, 8, 9 and 10) the facility failed to ensure documentation of when the Medical Doctor (MD) is notified of patient (Pt)arrival, documentation of MD arrival time, documentation of MD exam time, and/or all entries are signed, dated and timed by the author.

Findings include:

Facility policy titled Emergency Room Documentation states under #4. "The name of the ER (emergency room) doctor, A) Time they were notified B) Time they arrived. May indicate "here if MD was immediately available. #35. Specific MD orders." The policy does not address signing, dating and timing all entries and does not include date and time with item #35.

Pt #1's MR reviewed by surveyor 18816 on 4/7/10 at 9:00 AM revealed there is no documented time the MD was notified of the Pt's arrival, no documented time the MD arrived or when the MD performed the Medical Exam (ME) and the MD that wrote the discharge instructions did not sign, date or time the entry. This is confirmed in interview with Quality Improvement Coordinator (QIC) G on 4/7/10 at 2:15 PM.

Pt #3's MR reviewed by surveyor 18816 on 4/7/10 at 11:25 AM revealed there is no documented time the MD was notified of the Pt's arrival and no time the MD performed the ME. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #4's MR review by surveyor 18816 on 4/7/10 at 11:35 AM revealed there is no documented time the MD performed the ME and the MD that wrote the discharge instructions did not sign, date or time the entry. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #6's MR review by surveyor 18816 on 4/7/10 at 12:06 PM revealed the MD that wrote the discharge instructions did not sign, date or time the entry. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #7's MR review by surveyor 18816 on 4/7/10 at 12:25 PM revealed the MD that wrote the discharge instructions did not sign, date or time the entry. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #8's MR review by surveyor 18816 on 4/7/10 at 12:36 PM revealed there is no documented time the MD was notified of the Pt's arrival, no documented time the MD performed the ME, and the MD that wrote the discharge instructions did not sign, date or time the entry. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #9's MR review by surveyor 18816 on 4/7/10 at 12:43 PM revealed the MD that wrote the discharge instructions did not sign, date or time the entry. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.

Pt #10's MR review by surveyor 18816 on 4/7/10 at 12:55 PM revealed there is no documented time the MD was notified of the Pt's arrival, no documented time the MD performed the ME, and the MD that wrote the discharge instructions did not sign, date or time the entry. This is confirmed in interview with QIC G on 4/7/10 at 2:15 PM.