HospitalInspections.org

Based on closed record review, staff interview and review of facility documents, it was determined that the facility staff failed to ensure Emergency Department patients' medical needs were assessed and monitored per protocol for three of six patients (those leaving against medical advice (AMA) and leaving without being seen/treated (LWOT) in the survey sample of six closed records (Patients #3, 5, and 6).

The findings include:

1. During closed record review, Patient #3's record identified the patient left the ED without being seen by the physician. The patient was a 40 year old who presented to the ED with complaint of chest pain and increased blood sugar on 12/2/09; urgency level: ESI 3 (conditions include those problems that require definitive management requiring more than 2 resources). She was Triaged at 13:55 (1:55pm) but her chest pain was not assessed or documented by the Registered Nurse (RN); she was not moved to the treatment area for immediate interventions per protocol for presenting "chest pain." An EKG was conducted at 14:41 (2:41pm) (approximately 45 minutes after arrival). The nursing staff called for the patient at 16:50 (4:50 pm) and 16:55 (4:55 pm) (three hours after arrival for chest pain) but it was determined the patient had left the ED without being seen by the physician (LWOT).

During interview with the Director of ED/Critical Care on 2/23/10 at 2:30 PM, she stated all patients presenting with chest pain should have an EKG performed within 5 minutes of arrival. She noted the facility's protocol required that patient's pain should be assessed and documented during initial Triage and frequently thereafter. She could not determine that Patient #3's chest pain had been assessed and monitored by the RN.

The closed record identified the EKG was performed at 14:41 (2:41pm) and the RN provided the ED physician the initial report but there was no documentation at that time as to whether Patient #3 had history of cardiac problems or not (after the patient left the ED, the final report revealed a "normal" EKG). There was no evidence provided that the ED physician had adhered to the facility's policy for immediate interpretation and specific orders as needed. The "ED EKG Verification" form was not documented for Patient #3. The facility's "ED EKG Verification" form (to be used by the physician to record initial interpretations) contained the following:
"...time, interpretation, orders-MTA immediately, repeat EKG, initiate STEMI, initiate chest pain protocol and physician's signature."

2. Patient #5 was a 24 year old male who presented to the ED with chest pain complaints on 12/26/09 at 19:25. He was Triaged at 19:35 and reported his pain as "10" (identified as severe by the numeric pain intensity scale, see below); urgency ESI level 3. There was no evidence provided that the patient was immediately taken to the treatment unit (per chest pain protocol). An EKG was conducted at 19:30 but there was no documentation the RN presented the results to the ED physician for immediate interpretation and/or interventions. At 20:53 (1+ hours later), Patient #5 told the ED clerk he was leaving (without being seen by the physician). Later, the actual EKG print-out recorded: "sinus rhythm, anterior T wave changes are borderline abnormal...compared to the previous tracing, anteroseptal ST-T wave changes are new."

The Director of ED/Critical Care was interviewed on 2/23/10 at 2:25 PM and stated it was expected that the RN would ensure the EKG results were presented to the ED physician for interpretation. She stated the Triage Registered Nurse (RN) should assess for pain, document, and initiate interventions per protocol. The Director reviewed the record and noted Patient #5 reported a "10" pain level but she could not see documentation where the RN initiated pain reduction for the patient or whether the RN continued to reassess his pain level.

The following facility policies were reviewed for each patient in the survey sample:

-Review of the facility's "Pain Management" policy the following was recorded: "...1. (hospital) respects and supports the patients's right to optimal pain assessment, reassessment and management. ...3. All patients will be assessed for the presence, absence, and history of pain...I. An initial pain assessment...will be done at time of admission. II. Pain will be reassessed any time during the hospitalization when the patient reports continued or new onset of pain. III. Pain management is an established part of all Standards of Care...VII. Pain shall be assessed and managed according to the patient's reported scale of pain...a. The 0-10 numeric pain intensity scale: 0=no pain, 1-2=mild pain, 3-6=moderate pain, and 7-10=severe pain..."

-The ED's "Clinical Pathways" for chest pain included the following assessment/interventions:
"...pain assessment, EKG, labs, nursing interventions, chest pain protocol..."

-Review of the facility's "Assessment and Reassessment in the ED" policy recorded the following:
"...1. A RN will perform the ED Triage/Initial assessment...within a reasonable period of time...3. Reassessment is based upon patient's clinical status. 4. Documentation reflects the patient's course of treatment in the ED."

-Review of the facility's "Clinical Competency Checklist" recorded RNs would be competent to conduct EKGs for the ED. Review of the RNs personnel record on 2/24/10 revealed each RN was competent to conduct the EKGs and also, assess pain in ED patients.


25746

3. During a closed record review of Patient #6's medical record on 2/24/10 the following was noted. Patient #6 was a 5 year old who was initially triaged on 12/28/09 at 4:56 P.M. Patient #6 had her head hit with a car door and had redness and swelling to both temples. Patient #6 left the ED without being seen by the physician on 12/28/09 at 6:00 P.M. Pt. #6's pain was not assessed and monitored during the ED visit

The triage nurse documented Patient #6's pain as "utr".

On 2/24/10 the Director of the ED and Critical Care was interviewed and asked to review the medical record of Patient #6. She explained "utr" meant "unable to rate." She stated, "That is ("utr") unacceptable. There are ways of rating pain other than on a number scale of 0-10." "She (the triage nurse) could have used the facial expression chart (Wong-Baker Faces Pain Rating Scale) or could have described what the patient looked like; grimacing etc." "If she (the triage nurse) was truly unable to rate the patient's pain she (the triage nurse) should have documented why she (the triage nurse) could not rate the pain.

Patient #6 left the ED at 6:00 P.M. without being seen by the physician.