HospitalInspections.org

Based on document review and interview, nursing services failed to document patient's pain scale during triage assessment and initiate plan of care, failed to provide teaching related to pain assessment 5/10 in patient's medical record, failed to give articles found on its premises to security immediately after discovery of patient belongings in 1 of 10 patient medical records reviewed (patient 4).

Findings Include:

1. Review of policy titled: Emergency Department Documentation 678-202, PolicyStat ID: 9189245, last revised 02/2021: indicated under Definition 2. A plan of care will be initiated on admission to the Emergency Department for every patient and is based on the assessment of the patient in conjunction with the therapy prescribed by the responsible licensed medical practitioner. The plan of care is based on broad problems, goals, interventions, evaluation of outcomes, and discharge teaching. 4. Electronic documentation includes F. Initial vital signs and pain scale. J. Patient history, nursing assessment, and periodic reassessment as indicated by the patient's condition. Action Steps: 2. The ED RN will: B. Complete or verify that vital signs including pain assessment has been done. D. Initiate plan of care. H. Document all patient teaching in the electronic medical record.

2. Review of policy titled: Care of Articles of Value - ADMIN-129, PolicyStat ID: 7913979, last approved 04/2020, indicated under Action Steps: B. Found articles of value: 1. SVARH Personnel will: a. Give articles found within St Vincent Anderson Regional Hospital or on its premises to Security immediately.

3. Review of patient 4's medical record (MR) lacked documentation of patient pain assessment during triage assessment. MR lacked documentation of intervention for pain rating of 5/10 prior to discharge and no indication provider was notified.

4. Facility failed to provide Security Log indicating P4's personal belongings documented and returned to patient.

5. In interview on 10/07/24 at approximately 2:32 pm, N1 (Registered Nurse, Manager Emergency Department) confirmed P4's MR lacked documentation of pain assessment during patient triage, per policy, and not documented until approximately 7:50 pm during patient discharge. N1 confirmed P4's MR lacked patient education/teaching regarding patient pain score of 5/10 in patient plan of care during discharge, per policy. N1 confirmed security was not notified of P4's belongings when discovered, per policy.