HospitalInspections.org

Based upon review of medical record and interview with staff the requirements of 482.55 were not fully implemented:

Findings:

a. During review of medical record during the initial assessment of the patient an 80 year old female ESI-3 was conducted by a provider at 4:41pm on July 16, 2015 whose chief complaint was abdominal pain and nausea. A thorough hands -on assessment with assessment of the patients abdomen was not conducted by the provider who initially assessed the patient. The patient pain level was described as 7 out of 10. There were no medication given for pain or nausea. Labs and a computed tomography (CT) was ordered and given. The patient was asked to sit in the busy emergency department's waiting room until 11:00pm (7 hours). When the patient was finally re-assessed her pain level was described as 8 out of 10 on the pain scale. No re-assessment of pain or nausea was conducted from time of initial assessment to time of seeing physician provider.

b. Interviewed staff #3, Nurse Director of Emergency department at 1:20pm on November 20, 2015 in the administration conference room who agreed patient should have had a hands on initial assessment and pain should have been re-assessed during time of waiting to see a provider in the waiting room while waiting to see physician provider.