HospitalInspections.org

Based on interview, record review and document review, the facility failed to ensure a registered nurse supervised and evaluated the nursing care for 10 patients in the Emergency Department as evidenced by: nursing staff failed to reassess patients after the administration of pain medication per facility policy and administer medication as ordered by a physician to patients who were admitted and treated in the Emergency Department (A-0395).

The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutorily mandated care to its patients.

Based on interview, record review and document review, the facility failed to ensure patients in the Emergency Department received follow-up assessments after the administration of pain medication and failed to ensure medications were administered per physician order for 10 of 27 sampled patients (#7, #9, #10, #19, #22, #3, #2, #6, #8, #18).

Findings include:

1. Patient #7 presented to the Emergency Department on 07/04/10 at 12:17 AM, with a chief complaint of the patient fell down the stairs hitting the right side of abdomen on a stool at the bottom, extensive swelling on right side and a complaint of right hand and thumb pain.

The Emergency Department triage note documented the patient's pain level was 3 out of 10 on a numeric pain scale.

The Emergency Department Treatment Record, dated 07/04/10, documented an order for Morphine 10 milligrams (mg) and Zofran 4 mg to be administered by intramuscular injection (IM). The medication order did not include a documented time the order was written. The record lacked documented evidence the Morphine and Zofran was administered as ordered.

On 07/21/10 at 10:00 AM, Employee #1 reviewed the record and confirmed there was no documentation the Morphine and Zofran was administered as ordered. There was no documentation indicating the reason the medications were not administered as ordered.

2. Patient #9 presented to the Emergency Department on 05/20/10 at 1:34 PM, with a chief complaint of migraine headache with photophobia.

The Emergency Department triage note documented the patients pain rating was a 10 out of 10 on a numeric pain scale.

The Emergency Department Treatment Record documented the patient was given Toradol 60 mg IM, Reglan 10 mg IM, Benadryl 25 mg IM, and Zofran 4 mg by mouth. There was no documented evidence the patient was re-assessed 30 minutes after medication was administered. There was no documentation the patient's pain was re-assessed prior to discharge at 2:47 PM.

On 07/20/10 in the afternoon, Employee #3 indicated the patient was in the waiting room and was discharged from the waiting room. Employee #3 indicated the patient's pain level should have been re-assessed and documented in the record.

3. Patient #10 presented to the Emergency Department on 05/18/10 at 9:21 AM, with a chief complaint of neck and back pain.

The Emergency Department triage note documented the patient's pain rating was 10 out of 10 on a numeric pain scale.

The Emergency Department Treatment Record documented the patient was given Morphine 4 mg IM, Phenergan 25 mg IM and Valium 10 mg by mouth at 10:10 AM. The record lacked documented evidence the patient was re-assessed 30 minutes after the medication was administered. There was no documentation the patient's pain was re-assessed. The patient remained in the waiting room after the medications were administered.

The triage noted documented the patient's respiratory rate was 85 and the respirations were regular and unlabored. There was no additional vital signs documented after the initial vital signs taken at 9:21 AM.

On 07/20/10 in the afternoon, Employee #3 indicated the patient should have been re-assessed by the registered nurse.

4. Patient #19 presented to the Emergency Department on 04/28/10 at 10:39 PM, with a clinical impression of acute alcohol withdrawal.

The Emergency Department Treatment Record, dated 04/18/10, documented an order for Ativan 1 mg to be administered by IM injection and an order for Ativan 2 mg to be administered by IM injection. The Ativan 1 mg was administered at 10:48 PM and the Ativan 2 mg was administered at 12:41 AM. The record lacked documented evidence the patient was re-assessed after the Ativan was administered at 10:48 PM and 12:41 AM.

On 07/20/10 in the afternoon, Employee #3 indicated the patient should have been re-assessed 30 minutes after the Ativan was administered. The assessment should be documented in the nursing notes and there should be documentation regarding why another dose of Ativan was administered at 12:41 AM.

5. Patient #22 presented to the Emergency Department on 04/30/10 at 9:37 PM, with a chief complaint of entire back pain with tingling in left foot and leg.

The Emergency Department triage note documented the patient's pain level was 10 out of 10 on a numeric pain scale.

The Emergency Department Treatment Record, dated 04/30/10, documented an order at 10:15 PM, for Morphine 8 mg IM x1 and Ativan 1 mg IM x1. The medication was administered at 10:55 PM.

A review of the Emergency Department record revealed the patient was discharged home with his family at 10:56 PM. There was no documentation the patient was re-assessed after the pain medication was administered.

On 07/20/10 at 2:00 PM, Employee #3 indicated the facility policy was to hold the patient for 30 minutes after Ativan and Morphine was given and to reassess the patient. Employee #3 indicated the patient was in the waiting room and was discharged from the waiting room. Employee #3 confirmed there was no documentation nursing reassessed the patient 30 minutes after the Ativan and Morphine was administered.

6. Patient #3 presented to the Emergency Department on 07/06/10 at 9:24 AM, with a chief complaint of bilateral leg pain since 2:00 AM, Emergency Medical Services present, 5 mg Morphine given prior to arrival.

The Emergency Department triage note documented the patient's pain level was 6 out of 10 on a numeric pain scale.

The Emergency Department Treatment Record, dated 07/06/10, documented Morphine 5 mg IVP (intravenous push) prior to arrival and Percocet 10 mg by mouth (verbal order). The Percocet order was not timed and there was no frequency identified.

A review of the record revealed the patient did not receive the Percocet as ordered by the physician and there was no documentation the patient's pain level was reassessed.

On 07/20/10 at 2:00 PM, Employee #3 indicated the patient had informed nursing he usually took 30 mg of Morphine by mouth daily and he did not receive enough pain medication from the Emergency Medical Services.

7. Patient #2 presented to the Emergency Department on 05/02/10 at 3:09 PM, with a chief complaint of low back pain since early morning.

The Emergency Department triage note documented the patient's pain was a 4 out of 10 on a numeric pain scale.

The Emergency Department Treatment Record, dated 05/02/10, documented an order written at 3:15 PM, for Dilaudid 1 mg IM. A handwritten note next to the Dilaudid order documented, "NO RIDE."

A review of the record revealed the Dilaudid was not administered; there was no documentation the patient's pain was reassessed and the patient was discharged from the waiting room at 3:57 PM.

On 07/20/10 at 2:00 PM, Employee #3 indicated the patient did not receive the Dilaudid as ordered. The patient was discharged from the waiting room with an order for Vicodin.

The facility's "Medication Administration Pilot - Pilot Guideline for Medication Administration in Triage" policy, dated 09/30/2009, documented the following: "...Any medication administration will follow the current Policy and Procedure for administration at (name of hospital)...Recommendation Re-Vital and Re-Assess in 30 minutes for narcotics or vasoactives, 60 minutes for non-narcotic and non-vasoactive medications, every 2 hours for all other patients..."

The facility's "Interdisciplinary Pain Management" policy, dated 07/09, documented the following: "...Pain Assessment and Reassessment: An assessment and reassessment will be performed and documented: 5.1.1 Upon admission to the hospital or intake...5.1.4 After every pain relieving intervention...5.1.4.2.2 Injectable agent: Reassess thirty (30) minutes after administration of medication..."


21794


8. Patient #6 was a 62 year-old who presented to the Emergency Department on 7/3/10 at 4:54 AM, with a chief complaint of neck, shoulder and arm pain incurred from a motor vehicle accident. The patient's pain rating upon initial assessment was a 8 out of 10 on a numeric pain scale.

The Emergency Department Treatment Record documented the patient was administered Lortab 7.5/500 mg PO (by mouth) and Flexeril 10 mg PO at 5:15 AM. Following the completion of cervical X-rays the patient was returned to the Emergency Department and discharged with a pain rating of 7 out of 10 at 6:02 AM. There was no evidence the patient was re-assessed following the 30 minutes after the medication was administered at 5:15 AM.

9. Patient #8 was a 21 year old who presented to the Emergency Department on 7/2/10 at 10:00 AM, with a chief complaint of lower back pain. The patient's pain rating upon initial assessment was a 5 out of 10 on a numeric pain scale.

The Emergency Department Treatment Record documented the patient was administered Lortab 7.5/500 mg., Soma 350 mg and Motrin 600 mg at 10:45 AM. There was no documented evidence the patient was re-assessed 30 minutes after the medication administration. The patient was discharged following an X-ray series of the Lumbar Spine at 11:38 AM.

10. Patient #18 was a 49 year-old who presented to the Emergency Department on 7/1/10 at 2:55 PM, with a chief complaint of left shoulder pain, bilateral knee pain, low back pain and neck pain following being hit by a car while on an electric scooter. The patient's pain rating at 3:17 PM was a 8 out of 10 on a numeric pain scale.

The Emergency Department Treatment Record documented the patient was administered Morphine 4 mg IVP (intravenous push) and Zofran 4 mg IVP at 3:40 PM. During the patient's stay, various Computerized Tomography scans were ordered with negative results evident. However, at 1800, the patient was administered a second dose of Morphine 4 mg IVP with no documented evidence of a 30 minute re-assessment following the administration.