HospitalInspections.org

Based on policy review, medical record review and staff interviews, the hospital failed to complete pain reassessments in 2 of 10 medical records reviewed (Patient #9, Patient #16) and failed to complete discharge reassessment of vital signs within one hour of admission/discharge in 3 of 10 records reviewed in the emergency department. (Patient #9, Patient #13, Patient #16)

The findings include:

Review on 08/09/2023 of the policy ASSESSMENT - REASSESSMENT OF THE EMERGENCY DEPARTMENT PATIENT, Date of Issue: 07/13/2021 revealed "...IV. INTERVENTION A. Triage Assessment ...2. Triage assessment by the RN (Registered Nurse), as outlined in the documentation tool includes, at a minimum: ...d. Presence of pain ...f. Vital Signs...C. Reassessment ...1. Reassessment of initial assessment findings are required, at minimum, every 4 hours, or more frequently with change of condition...3. Additionally, responses to treatment, ...this includes a reassessment of pain after medication administration or other non-pharmacologic (without medicine use) intervention to relieve pain was performed. 4. Vital signs will be reassessed every 4 hours or more frequently based on patient condition...5. Reassessment of vital signs will be documented within one hour of admission, discharge, or transfer..."

1.A. Closed medical record review on 08/09/2023 for Patient #9's visit #1, revealed a 54-year-old female patient who presented to the emergency department (ED) on 01/28/2023 via emergency medical services (EMS) from a skilled nursing home (SNF) at 1331 for complaints of abdominal pain with her feeding tube clogged and not flushing. Patient #9 had a history of Multiple Sclerosis (an immune disease in which the body's immune system attacks its own tissues). Vital Signs at 1352 were Temperature 98.4, Blood Pressure 124/75, Heart Rate: 96, Respirations 17, Oxygen Saturation (percent of oxygen in the blood) 98% on room air, and Pain Assessment was a 10 of 10 (1 being the least pain, and 10 being the most pain) in the abdomen. An emergency severity index (ESI) of 3 (urgent) was assigned by the triage nurse. Medication Orders were placed at 2108 for Morphine 2 milligrams (mg) injection by Medical Doctor (MD) #2. Morphine (controlled medication for severe pain) 2 mg was given intramuscular (IM) in the right deltoid (upper arm) at 2110 by RN #3. MD #2 at 2207, set the Discharge Disposition for Patient #9 to be discharged. Vital Signs at 2213 were documented as Heart Rate 89, Respirations 20, Blood Pressure 120/71, Oxygen Saturation of 99 % on room air by RN #3. Medical record review failed to reveal a pain reassessment was performed after the 2110 pain medication administration. Patient #9 was discharged back to the skilled nursing facility (SNF) via transport on 01/29/2023 at 0654 by RN #4.

Request on 08/09/2023 to interview RN #3 revealed the RN was unavailable for interview.

Interview on 08/10/2023 at 0834 with RN #4 revealed the RN remembered Patient #9. Interview revealed "...Pain reassessment should be completed one hour after medication administration and would include a pain score..." Interview revealed hospital policy for pain reassessment after pain medication was not followed for Patient #9.

Interview on 08/10/2023 at 1700 with Interim ED Nurse Manager revealed "...The nurse should reevaluate pain a minimum of every 4 hours per policy...our documentation needs improvement. We know we need to work on it..." Interview revealed a pain reassessment should have been completed before Patient #9 was discharged. The interview revealed hospital policy for pain reassessment every 4 hours and after an intervention was not followed for Patient #9.

Closed medical record review on 08/10/2023 for Patient #9's visit #2 revealed, a 54-year-old female patient who presented to the emergency department (ED) on 02/05/2023 via EMS from a SNF at 0830 for complaints of bleeding from a biliary drainage tube from gallbladder placed during a previous hospital admission. Patient #9 had a history of a feeding tube and multiple sclerosis. Vital Signs at 0904 were Temperature 97.8, Heart Rate 77, Respirations 15, Oxygen Saturation 97 % on room air with a Pain Assessment of 10/10 in the abdomen and was assigned an ESI of 3 (urgent) by RN #5. Medication Orders were placed at 1500 for Oxycodone- immediate release tablet 10 mg by MD #6. At 1905 Oxycodone 10 mg was given via feeding tube by RN #7 and Respirations were documented of 18. Medical record review failed to reveal a pain reassessment was performed after the 1905 oral pain medication administration. Vital Signs at 2227 were Temperature 97.8, Heart Rate 80, Respirations 20, Blood Pressure 95/74, Oxygen Saturation of 98 % on room air and at 2228 Departure Condition was documented as "good" by RN #7. Patient #9 was discharged back to the SNF via transport on 02/05/2023 at 2235.

Request on 08/10/2023 to interview RN #7 revealed the nurse was unavailable for interview.

Interview on 08/10/2023 at 1700 with Interim ED Nurse Manager revealed "...The nurse should reevaluate pain a minimum of every 4 hours per policy...our documentation needs improvement. We know we need to work on it..." Interview revealed a pain reassessment should be completed after pain medication administration and before patient discharge. The interview revealed hospital policy for pain reassessment was not followed for Patient #9.

1.B. Closed medical record review on 08/09/2023 revealed Patient #16, a 28-year-old female patient who presented to the ED on 02/13/2023 at 0859 for lower back pain and bilateral lower extremity pain with sickle cell disease and was out of pain medication at home. Patient #16 had a history of Sickle Cell Disease (cells die early, leaving a shortage of healthy red blood cells and can block blood flow causing pain). Vital Signs at 0905 were Temperature 98.0, Heart Rate 91, Respirations 17, Blood Pressure 117/55, Oxygen saturation of 96% on room air, and a Pain Assessment of 7/10 in the lower back and was assigned and a ESI 2-emergent by RN #8. Medication Orders were placed at 0916 by MD #9 for Ondansetron (medication for nausea) 4 mg; ketorolac (non-narcotic pain medication for moderate pain) injection 15 mg; and Morphine (narcotic medication for severe pain) injection 4 mg. At 0920 a peripheral intravenous #20 gauge was started in the right forearm by RN #10. At 0920 all medication orders were administered via IV by RN #10. Ondansetron injection 4 mg was given via IV again at 1050 by RN #10. At 1238 more Medication Orders were placed by MD #9 for Morphine 5 mg, and Acetaminophen (medication for mild pain) 1000 mg by mouth. Medication Orders were administered at 1315 by RN #11, with Respirations of 18 and a Pain Assessment of 7/10. MD #9 at 1414 set the Disposition to Discharge. Morphine 5mg IV was given at 1442 by RN #10 and a Pain Assessment of 7/10 with Respirations of 18 were completed. At 1520 Discharge Condition was completed as "good" by RN #10. Record review failed to reveal a pain reassessment was completed after the 1442 pain medication administration prior to discharge. Patient #16 was discharged "to self" on 02/13/2023 at 1533.

Interview on 08/10/2023 at 0910 with RN #10 revealed the RN did not recall Patient #16. Interview revealed "...We try to reassess one hour after pain medication was given. I should have reassessed her pain at discharge..." Interview revealed hospital policy was not followed for Patient #16 for pain reassessment.

Interview on 08/10/2023 at 1700 with Interim ED Nurse Manager revealed "...The nurse should reevaluate pain a minimum of every 4 hours per policy...our documentation needs improvement. We know we need to work on it..." Interview revealed a pain reassessment should be completed after pain medication was administered and before patient discharge. The interview revealed hospital policy for pain reassessment was not followed for Patient #16.

2.A. Closed medical record review on 08/09/2023 for Patient #9's visit #1, revealed a 54-year-old female patient who presented to the emergency department (ED) on 01/28/2023 via emergency medical services (EMS) from a skilled nursing home (SNF) at 1331 for complaints of abdominal pain with her feeding tube clogged and not flushing. Patient #9 had a history of Multiple Sclerosis (an immune disease in which the body's immune system attacks its own tissues). Vital Signs at 1352 were Temperature 98.4, Blood Pressure 124/75, Heart Rate: 96, Respirations 17, Oxygen Saturation 98% on room air, and Pain Assessment was a 10 of 10 (1 being the least pain, and 10 being the most pain) in the abdomen, and an emergency severity index (ESI) of 3 (urgent) was assigned by the triage nurse, RN #1. The Discharge Disposition was selected at 2207 "set to discharge" by MD #2. Vital Signs at 2213 were documented as Heart Rate 89, Respirations 20, Blood Pressure 120/71, and Oxygen Saturation of 99 % room air by RN #3. Record review failed to reveal vital signs were completed from 01/28/2023 2213 through 01/29/2023 at 0654 (8 hours and 41 minutes). Patient #9 was discharged back to the skilled nursing facility via transport on 01/29/2023 at 0654 by RN #4.

Interview on 08/10/2023 at 0834 with RN #4 revealed the RN remembered Patient #9. Interview revealed "...Reassessment before discharging a patient included repeat vital signs and pain score. This should be included in the Departure Condition." Interview revealed Patient #9 should have had vital signs completed before discharge. Interview revealed hospital policy was not followed for discharge reassessment of vital signs for Patient #9.

Interview on 08/10/2023 at 1630 with ED Nurse Director revealed "...Discharge reassessment with vital signs should be completed within one hour of discharge. She should have had a discharge assessment..." Interview revealed hospital policy was not followed for discharge reassessment of vital signs for Patient #9.

2.B. Closed medical record review on 08/09/2023 revealed Patient #13, an 86-year-old female who presented to the ED on 02/24/2023 at 1637 with her daughter for a recent fall "shoulder looked injured according to occupational therapist." Patient #13 was assigned an ESI 3-urgent by RN #14. MD #12 was assigned and a left shoulder, left knee and left hip x-ray was ordered at 1651. The X-rays resulted at 1717 as negative, and at 1741 the ED Disposition was "set to discharge" by MD #12. The Discharge Condition was completed at 1810 by RN #14 as "good", and Patient #13 had a splint application to the left arm. Record review failed to reveal any vital signs were completed during the 02/24/2023 ED encounter (1 hour and 34 minutes). At 1811 Patient #13 was discharged home with daughter.

Request on 08/09/2023 to interview RN #14 revealed the nurse was unavailable for interview.

Interview on 08/10/2023 at 1630 with ED Nurse Director revealed "...The patient should have had vital signs on admission..." Interview revealed hospital policy was not followed for assessment of vital signs for Patient #13.

2.C. Closed medical record review on 08/09/2023 revealed Patient #16, a 28-year-old female patient who presented to the ED on 02/13/2023 at 0859 for lower back pain and bilateral lower extremity pain with sickle cell disease and was out of pain medication at home. Patient #16 had a history of Sickle Cell Disease (cells die early, leaving a shortage of healthy red blood cells and can block blood flow causing pain). Vital Signs at 0905 were Temperature 98.0, Heart rate 91, Respirations 17, Blood pressure 117/55, Oxygen Saturation of 96% on room air, and Pain Assessment of 7/10 in the lower back and was assigned and ESI 2-emergent by RN #8. Record review failed to reveal vital signs were completed prior to being discharged (5 hours and 28 minutes). Patient #16 was discharged 02/13/2023 at 1533.

Interview on 08/10/2023 at 0910 with RN #10 revealed the RN did not recall Patient #16. Interview revealed discharge vital signs should be completed and documented before discharge. Interview revealed hospital policy for discharge assessment of vital signs was not followed for Patient #16.

Interview on 08/10/2023 at 1630 with ED Nurse Director revealed "...Discharge reassessment with vital signs should be completed within one hour of discharge..." Interview revealed hospital policy was not followed for discharge reassessment of vital signs for Patient #16.

NC00205573