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Based on record review, staff interview and facility policies and procedures, it was determined that nursing staff failed to initiate medication administration according to physician orders for one (1) (patient #1) of ten (10) patient records reviewed which resulted in the patient experiencing prolonged pain.

Findings include:

Review of patient #1's medical record revealed that he/she arrived to the Emergency Department (ED) at 11:58 a.m. on 2/4/18 via air ambulance after being involved in a motor vehicle accident. A history and physical was completed at 12:42 p.m. by credential #14 that revealed the patient had abrasions to the left hip, left ankle, left posterior (back of) knee and right knee laceration. Blood tests, x-rays, and CAT scans were all completed that revealed multiple pelvic fractures, left ankle fracture and displacement. The record revealed that the right posterior knee laceration was cleaned and sutured. A physician order was written at 2:07 p.m. for patient #1 to be admitted. Other orders written at 2:07 p.m. included monitoring, bedrest, nothing by mouth, oxygen as needed, and intravenous (plastic tube inserted in a vein) fluids of normal saline at 125 c.c. per hour. Credential #12 examined the patient at 1:49 p.m. and documented that the plan of care included surgery on 2/5/18 and wrote orders for pain medication as needed. Credential #12 documented injuries to the right knee and right thigh. Staff #10 documented at 4:00 p.m. that a splint (immobilizer) was applied to the patients left leg by credential #12. An order for a regular diet was entered after the splint was applied. At 4:47 p.m., patient #1's parents arrived at the facility.

An interview with staff #10 took place in the Accreditation conference room on 5/1/18 at 10:30 a.m. Staff #10 was a RN and took care of patient #1 from the time he/she arrived in the ED until approximately 7:00 p.m. He/she recalled that patient #1 was not allowed to eat until approximately 3:30 p.m. He/she recalled that the patient was given a 'box lunch' that consisted of a sandwich, chips, piece of fruit and drink prior to his/her parents arrival. He/she was not aware of the patient requesting additional food. He/she stated that the patient had an injury to the back of his/her knee that required sutures. Staff #10 stated that the patient was medicated prior to having his/her ankle reduced (displacement manually put back in place). He/she did not recall the patient requesting additional pain medication. He/she stated that all patients who arrived at the ED with trauma injuries received intravenous (IV) fluids. In the ED, IV fluids were generally administered by gravity (without using an IV pump). He/she did not recall changing the patients IV fluids.

Patient #1's medical record revealed that at 7:25 p.m. staff #6 documented that the requested pain medicine for a pain score of six (6) out of ten (10). The patient received acetaminophen by mouth at 8:30 p.m., morphine intravenously at 8:33 p.m. and Oxycodone by mouth at 8:34 p.m. Staff #6 documented that the patient reported a pain score of five (5) out of ten (10) at 9:00 p.m. The patient was transferred to an inpatient room 2/5/18 at 12:30 a.m. Review of patient #1's medical record revealed that normal saline intravenous fluids were administered at 125 c.c. per hour beginning at 3:00 a.m. on 2/5/18.

A phone interview with staff #6 was conducted on 5/1/18 at 10:45 a.m. from the Accreditation conference room. He/she was a RN and worked in the ED. He/she recalled that patient #1 had been in a major motor vehicle crash. Staff #6 recalled administering pain medication to patient #1 and positioning his/her leg for comfort. Staff #6 stated that patient #1 or his/her parent did not voice complaints about the care provided.

An interview took place in the Accreditation conference room on 5/1/18 at 10:15 a.m. with staff #9. Staff #9 was the director of the emergency department (ED). He/she did not have record of a complaint regarding patient #1. He/she stated that patients are sometimes held in the ED until a patient room was available. He/she stated that the ED staff was expected to initiate any orders written while patients were held.

Review of the facility's procedure #206.1006, titled 'Pain Management', last revised 12/22/17 revealed that the facility policy was to ensure optimal patient comfort through proactive pain control measure that were mutually established with the patient, family and healthcare team. All patients were to be assessed for pain when admitted and after each intervention for pain or new report of pain. Patient's in the ED were assessed and treated according to the Pain protocol. Pain was assessed using an appropriate assessment tool. Documentation of pain should be documented in the medical record. Reassessment of pain should be documented with new reports of pain and after each intervention for pain once a sufficient time had elapsed for the treatment to take effect.

Review of the facility's procedure #206.1017, titled 'Plan for Nursing Care', last revised 11/29/17 revealed that professional nursing care included but was not limited to the following: assessment of the health status of individuals throughout the life span; establishment of nursing diagnosis, collaboration with the patient and/or family to establish goals; plan, implement and evaluate nursing care; provide safe and effective nursing care; collaboration with members of the healthcare team in the management of care; administration of medications, preparation for diagnostic studies and assist with treatments prescribed by a physician or other authorized provider, per approved protocol when authorized by law. The Chief Nurse Executive (CNE) had overall responsibility and accountability to ensure that nursing practice and care was operational in all areas that nursing care was provided.


Review of six (6) (#2, #3, #4, #5, #6, #7) staff files revealed that all required information was present.

Review of four (4) (#11, #12, #13, #14) credential files revealed that all required information was present.

Medical record review was conducted on nine (9) additional medical records (patient #2, patient #3, patient #4, patient #5, patient #6, patient #7, patient #8, patient #9, patient #10) focused on pain assessment and reassessment and discharge planning. There were no concerns identified.

Other facility documents reviewed included but was not limited to: Medical Staff Rules and Regulations, nursing staffing for 2/1/18 through 2/14/18 for the trauma/orthopedic unit and ED, quality management committee meeting minutes for February, March, and April 2018, complaint log for February, March, and April 2018.