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Based on medical record review, staff interview, and policy review, the facility failed to follow complete pain assessments in the emergency department (ED) during triage, at admission, prior to medication administration, and following medication administration. Additionally, the facility failed to ensure intakes were monitored as ordered and failed to provide assistance with feeding and bathing for patient's admitted.

See A385

Based on medical record review, policy review and staff interview, the facility failed to follow their policy to consult with an obstetrician based on the pregnant patient's presenting symptoms and failed to provide effective pain management for ongoing pain levels described as in the severe pain category for a patient in the emergency department (ED).

See A1103 and A1104

Based on record review, staff interview, and policy review, the facility failed to complete pain assessments in the emergency department (ED) during triage, at admission, prior to medication administration, and following medication administration for four (Patients #2, #19, #22 and #23) patients and failed to ensure oral intakes were monitored as ordered and assistance with feeding and bathing was provided for one (Patient #3) patient. 20 patient records were reviewed.

Findings include:

1. Review of the medical record revealed Patient #2 arrived to the ED on 01/28/25 at 12:58 AM. Nursing notes documented the patient was unable to sit still stating "Pain is worse when sitting." Triage was completed at 1:13 AM with notes stating this patient was complaining of abdominal pain with intermittent episodes of vaginal bleeding. No documentation was found of a pain level during triage. Nursing notes at 1:40 AM indicated security called the registered nurse (RN) due to this patient lying on the floor in the waiting room crying and stating she had left lower abdominal and rectal pain. The patient's pain score was 10 out of 10 on a one to ten scale. Nursing notes at 2:33 AM documented the patient left without being seen by the physician.

Patient #2 returned to the ED on 01/28/25 at 11:18 AM with complaints of vomiting. The notes referred to Patient #2 being in the ED earlier but left after triage and was not seen by a physician. This patient was complaining of diffuse abdominal pain and was actively vomiting.

Physician notes at 1:01 PM by Staff I stated the patient presented with abdominal pain and vomiting with the pain becoming severe around 1:00 AM. Patient #2 stated she was nervous something was causing her symptoms and stated her pain was currently a ten out of ten on a one to ten scale.

Physician orders were received and Patient #2 was given Morphine Sulfate four milligram (mg) intravenously (IV) at 1:19 PM due to complaints of abdominal pain. Patient #2 continued to complain of severe pain, rating it a nine on a one to ten scale and at 2:16 PM and was given Morphine two mg at 2:20 PM . A reassessment of pain was completed at 3:16 PM with Patient #2 stating the pain remained, rating a 10 out of 10 on a one to ten scale. A serum pregnancy test was ordered. The result was positive for pregnancy at 3:28 PM. At 4:00 PM, Patient #2 reported constant pain, rating it a ten on an one to ten scale. The pain was documented in the lower right and left side of the abdomen.

Patient #2 received Tylenol 1000 mg via an IV infusion at 5:52 PM. Patient #2 continued to rate the pain a ten on a one to ten scale. A pain assessment was completed at 6:13 PM when the Tylenol was infused with abdominal pain rated as nine on a one to ten scale and stated the pain was unchanged. The record contained no further pain assessments.

Review of the notes at 8:05 PM revealed the patient was requesting to leave after the urine results come back and the physician was informed. Nursing notes at 8:38 PM documented the patient left without receiving discharge instructions from the nurse.

Review of the facility policy titled "#C113 Pain Assessment, Management and Re-assessment" stated the purpose was to provide defined criteria and standardized tools to screen for, assess, and reassess pain. This policy then refers to Lippincott which instructs staff to document a pain assessment before and after pain medication is given. This policy defines severe pain as a number from seven through ten. Pain is assessed upon presentation to the emergency department, at the time of admission and prior to administration of medications. This policy further instructs staff to continue pain monitoring and documentation at the intervals outlined in Corporate Clinical Policy "Documentation by Nursing, Acute Care," which states pain should be monitored within one hour after pain intervention.

Interview on 06/03/25 at 4:30 PM, Staff A verified no pain assessment was completed in triage for the first visit on 01/28/25 at 12:58 AM and no pain re-assessment was completed after the IV Tylenol was administered.

2. The medical record revealed on 03/10/25 at 5:38 PM Patient #19, Gravida 3 Para 2, at five weeks gestation came to the ED with complaints of abdominal pain and vaginal bleeding. Triage was completed at 5:52 PM with a pain assessment documented at 8/10. Patient #19 was examined and discharged home at 11:09 PM with instructions to return if increase in bleeding or if pain increases. No further pain assessments were documented after the triage.

Interview on 6/10/25 at 5:00 PM, Staff A verified the findings of not completing a pain assessment upon admission to the ED.

3. The medical record revealed Patient #22 was admitted to the ED on 02/04/25 at 10:16 AM with complaints of right testicular pain and history of having groin surgery one week ago. Notes at 10:26 AM stated the patient was having right sided groin pain. No pain assessment of severity was completed.

Physician orders were received for the nonsteroidal anti-inflammatory Toradol 5 mg. The Toradol was given via IV at 1:31 PM. No pain assessment was completed prior to the administration of the Toradol. The patient was discharged at 1:33 PM.

Interview on 06/24/25 at 11:05 AM, Staff A verified the pain assessment at admission did not identify a severity rating and no assessment was completed prior to the administration of the Toradol.

4a. The medical record revealed Patient #23 came to the ED on 02/24/25 at 10:38 AM with complaints of sharp right groin pain since Friday night. Notes documented the patient had a history of lung cancer, which was in remission. Triage notes listed no pain. A provider assessed the patient at 11:58 AM and ordered pain medication. The pain medication Norco was given at 12:26 PM with no assessment of the patient's pain scoring. The patient's pain score was not assessed until 1:56 PM with a groin pain identified as 5/10.

Interview on 6/25/25 at 11:57 AM, Staff A verified Patient #23 came in with groin pain at 10:38 AM, received pain medication at 12:26 PM, but did not have a pain score documented until 1:56 PM.

b. Patient #23 returned to the ED on 03/26/25 at 3:28 PM complaining of pain under both sides of their ribs. On admission physician orders included to give pain medication. The muscle relaxant Zanaflex 4 mg and Tylenol were given at 6:51 PM. Toradol 15 mg was given intramuscularly (IM) at 6:53 PM. The patient was discharged home with a prescription for lidocaine patches at 8:11 PM. There was no documentation a pain assessment was completed during Patient #23's stay in the ED.

Interview on 6/25/25 at 11:57 AM, Staff A verified no documentation Patient #23 had a pain assessment was completed during his ED visit on 03/26/25.

5a. The medical record revealed Patient #3 was admitted to the ED with shortness of breath. A computerized tomography (CT) scan revealed a small pulmonary emboli with orders received to start IV Heparin. On 03/05/25 at 6:50 PM Patient #3 was admitted to the sixth floor.

A screening for activities of daily living (ADLs) was completed on 03/06/25 at 3:24 AM indicating the patient was dependent for care, listing maximum assistance was needed for feeding, dressing and grooming.

The nursing care plan dated 03/07/25 identified Potential for compromised adequate intake. Interventions included full assist with meals, food selections and eating. Review of meal tickets showed Patient #3 received meals on 03/05/25 at 6:29 PM, 03/06/25 at 8:00 AM, 12:38 PM and 6:26 PM, and on 03/07/25 at 9:37 AM. Review of the flowsheet on 03/06/25 at 8:00 AM listed under feedings the patient took in 0%. There was no intake documented on the other days meals were provided. There was no documentation Patient #3 was fed these meals.

The nursing care plan identified the patient was a full assist with bathing. There was no documentation of a bath offered or declined.

Interview on 06/04/25 at 4:55 PM, Staff A verified no documentation was found to indicate Patient #3's meal intakes or if the meals were fed to him. Staff A stated patients are to be offered a bath daily and this was to be documented on the flow sheets. Staff A verified there was no evidence Patient #3 was offered a bath during his stay.

b. Patient #3 had orders for intake and output (I&O) per shift. The nursing care plan dated 03/07/25 lists potential for compromised adequate intake. The record contains no documentation of oral intake to ensure hydration needs were met.

Review of the facility policy titled "Documentation by Nursing, Acute Care for Adult Medical/Surgical Units: Monitoring and Documentation Standards lists under I&O" reveals to monitor and document I&O per order every 12 hours.

Interview on 06/04/25 at 4:55 PM, Staff A verified the findings of not recording I&O per order and policy.

Based on medical record review, policy review and staff interview, the facility failed to follow their policy to consult with an obstetrician based on the pregnant patient's presenting symptoms. This affected one patient (Patient #2) who presented to the Emergency Department (ED) with severe abdominal pain, vomiting, and recent intermittent vaginal bleeding and one patient (Patient #19) who presented with complaints of abdominal pain and vaginal bleeding. This had the potential to affect all patients presenting to the ED of less than 20 weeks gestation with abdominal pain.


Findings:


1.Review of the medical record revealed Patient #2 arrived to the ED on 01/28/254 at 12:58 AM. Nursing notes documented the patient was unable to sit still stating "Pain is worse when sitting." Triage was completed at 1:13 AM with notes stating this patient was complaining of abdominal pain with intermittent episodes of vaginal bleeding. The patient reported she could be pregnant. No documentation was found of a pain level during triage. Nursing notes at 1:40 AM documented security called the registered nurse (RN) due to this patient lying on the floor in the waiting room crying and stating she had left lower abdominal and rectal pain. The patient's pain score was 10/10. Nursing notes at 2:33 AM documented the patient left without being seen by the physician.

Patient #2 returned to the ED on 01/28/25 at 11:18 AM with complaints of vomiting which started that day. These notes referred to Patient #2 being in the ED earlier however she left after triage and was not seen by a physician. The patient was complaining of diffuse abdominal pain and was actively vomiting.

Physician notes on 01/28/25 at 1:01 PM by Physician Staff I revealed the patient presented with abdominal pain and vomiting. The pain became severe around 1:00 AM with associated vomiting. Patient stated she was nervous something was causing her symptoms and stated her pain was currently a 10/10. The patient denied fever, chills, urinary symptoms, or diarrhea. The patient's last menstrual period was unknown but stated her periods are abnormal.

Orders were received and the patient was given the opiod pain medication Morphine Sulfate (MS) 4 milligram (mg) intravenously (IV) at 1:19 PM due to complaints of abdominal pain of 10 out of 10. Patient #2 continued to complain of severe pain at a 9/10 at 2:16 PM and was given another dose of MS 2 mg at 2:20 PM . A re-assessment of pain was completed at 3:16 PM with the patient stating pain remained 10/10. A serum pregnancy test was ordered with results at 3:28 PM showing the patient was pregnant.

A transvaginal ultrasound was ordered due to the patient being less than 14 weeks gestation.

An assessment at 4:00 PM documented constant pain of 10/10 in the lower right and left side of the abdomen. The patient went for the ultrasound at 4:30 PM.

The ultrasound report listed findings of a single live intrauterine pregnancy estimated gestational age eight weeks four days based on crown-rump length measurement. Fetal heart rate was 176 beats per minute and the gestational sac was grossly within normal limits. A large fluid collection likely adjacent to the gestational sac, measuring 4.9 centimeters (cm) by 6.8 cm by 2.2 cm, was noted. The ovaries were obscured by bowel gas artifact.

Notes from the Radiology Technician Staff R documented limited transvaginal imagine due to patient cooperation, patient refusal to complete full exam, and limited field of view due to pain tolerance. Image quality is limited due to patient movement and pain tolerance. There was no documentation an attempt to alleviate the patient's pain was provided.

Discharge notes by the ED physician documented the patient had been advised to follow up with their specialist within one week and to return to the ED if their symptoms change, worsen, new symptoms arise or if they have additional concerns. No documentation was found a pelvic exam was completed. There was no documentation an obstetrician was consulted to assess the patient due to her symptoms.

Notes at 8:05 PM revealed the patient was requesting to leave after the urine results come back and the physician was informed. Orders were placed for discharge by Physician Staff J at 8:14 PM. Nursing notes at 8:38 PM documented the patient left without receiving discharge instructions from the nurse.

Review of the policy titled "Obstetrical Patients Who Present to the Emergency Department: Communication and Treatment," dated 10/04/24, revealed women will receive obstetrical care based on the assessment of the needs and varying levels of gestational development. Staff will utilize the decision tree "OB Patient Presenting to the ED." The decision tree revealed if the patient was greater than 20 weeks and having obstetrical issues the patient will be evaluated in the labor and delivery area. If the patient was less than 20 weeks with obstetrical complaints such as abdominal pain, cramping, and vaginal bleeding, the patient will be evaluated in the ED and the ED is to notify the obstetric provider.

Interview with a Registered Nurse (RN) Staff Y on 06/02/25 at 4:00 PM revealed if a pregnant patient came to the ED greater than 20 weeks gestation and the reason was obstetrically related the patient would be transferred to the obstetric floor. If the patient was less than 20 weeks they will be assessed in the ED with the physician consulting with an obstetrician if needed. Physicians generally order a vaginal ultrasound after pregnancy is confirmed by a blood test to rule out ectopic pregnancy.

Interview with the Director of the ED, Staff K, on 06/03/25 at 1:25 PM revealed when patients come in with abdominal pain or complaints of cramping the physicians will order a urine test for pregnancy. If the pregnancy test is positive they order an ultrasound. We now have order sets built in to rule out ovarian torsion, ectopic pregnancy and testicular torsion. Staff K stated if the patient is less than 20 weeks gestation they do not always consult with the obstetrician. If the patient has an obstetrician who works at the hospital the ED physicians may consult with them, otherwise they have the patient follow up with their obstetrician. While reviewing the OB Patient Presenting to the ED decision tree Staff K stated the ED physicians do not call the obstetrician routinely if the patient was less than 20 weeks unless the patient had an issue or the patient requested the staff to call.

Interview with the Radiology Technician Staff R on 06/09/25 at 4:40 PM revealed Patient #2 was crying and moving a lot during the ultrasound. It was difficult to get good pictures. The patient initially refused transvaginal ultrasound and Radiology Technician Staff R explained the benefits with the patient agreeing to try it. Radiology Technician Staff R got a few images and took a few videos since she wasn't getting good pictures due to the patient moving around in pain and asking Radiology Technician Staff R to stop. Radiology Technician Staff R called the reading room and was transferred to the radiologist. She explained she wasn't getting good pictures to see the ovaries and if this was an ectopic pregnancy. The radiologist stated to attempt to get more pictures, but the patient refused and the exam ended.

2. The medical record revealed on 03/10/25 at 5:38 PM Patient #19, Gravida 3 Para 2, at five weeks gestation came to the ED with complaints of abdominal pain and vaginal bleeding. Triage was completed at 5:52 PM with a pain assessment documented pain at 8/10. Patient #19 was examined and discharged home at 11:09 PM with instructions to return if increase in bleeding or if pain increases. The record contained no evidence an obstetrician was consulted due to the patient's symptoms.

Based on medical record review, staff interview, and policy review, the facility failed to provide effective pain management for ongoing pain levels described as in the severe pain category for a patient in the emergency department (ED). This affected one patient (Patient #2) out of 20 ED patients reviewed.

Findings include:

Review of the medical record revealed Patient #2 arrived to the ED on 01/28/254 at 12:58 AM. Nursing notes documented the patient was unable to sit still stating "Pain is worse when sitting." Triage was completed at 1:13 AM with notes stating this patient was complaining of abdominal pain with intermittent episodes of vaginal bleeding. The patient reported she could be pregnant. No documentation was found of a pain level during triage. Nursing notes at 1:40 AM documented security called the registered nurse (RN) due to this patient lying on the floor in the waiting room crying and stating she had left lower abdominal and rectal pain. The patient's pain score was 10/10. Nursing notes at 2:33 AM documented the patient left without being seen by the physician.

Patient #2 returned to the ED on 01/28/25 at 11:18 AM with complaints of vomiting which started that day. These notes referred to Patient #2 being in the ED earlier however she left after triage and was not seen by a physician. The patient was complaining of diffuse abdominal pain and was actively vomiting.

Physician notes on 01/28/25 at 1:01 PM by Physician Staff I revealed the patient presented with abdominal pain and vomiting. The pain became severe around 1:00 AM with associated vomiting. Patient stated she was nervous something was causing her symptoms and stated her pain was currently a 10/10 on the pain scale with 10 being the worst pain experienced. The patient denied fever, chills, urinary symptoms, or diarrhea. The patient's last menstrual period was unknown but stated her periods are abnormal.

Orders were received and the patient was given the opiod pain medication Morphine Sulfate (MS) 4 milligram (mg) intravenously (IV) at 1:19 PM due to complaints of abdominal pain of 10 out of 10. Patient #2 continued to complain of severe pain at a 9/10 at 2:16 PM and was given another dose of MS 2 mg at 2:20 PM . A re-assessment of pain was completed at 3:16 PM with the patient stating pain remained 10/10. No pain medication was administered. A serum pregnancy test was ordered with results at 3:28 PM showing the patient was pregnant.

A transvaginal ultrasound was ordered due to the patient being less than 14 weeks gestation.

Vital signs were completed at 4:00 PM with constant pain of 10/10 documented in the lower right and left side of the abdomen. No pain medication was administered at this time. The patient went for the ultrasound at 4:30 PM.

The ultrasound report listed findings of a single live intrauterine pregnancy estimated gestational age eight weeks four days based on crown-rump length measurement. Fetal heart rate was 176 beats per minute and the gestational sac was grossly within normal limits. A large fluid collection likely adjacent to the gestational sac, measuring 4.9 centimeters (cm) by 6.8 cm by 2.2 cm, was noted. The ovaries were obscured by bowel gas artifact.

Notes from the Ultrasound Technician Staff R documented limited transvaginal imagine due to patient cooperation, patient refusal to complete full exam, and limited field of view due to pain tolerance. Image quality was limited due to patient movement and pain tolerance. There was no documentation an attempt to alleviate the patient's pain was provided

Patient #2 returned to the ED from the ultrasound at 5:30 PM. The patient received Tylenol 1000 mg via an IV infusion at 5:52 PM with pain score of 10/10 continuing. A pain assessment was completed at 6:13 PM when the Tylenol was infused with abdominal pain rated as 9/10 and notes stating pain unchanged. The record contained no further pain assessments and no further pain medication was administered.

Discharge notes by the ED physician documented the patient had been advised to follow up with their specialist within one week and to return to the ED if their symptoms change, worsen, new symptoms arise or if they have additional concerns.

Orders were placed for discharge by Physician Staff J at 8:14 PM. Nursing notes at 8:38 PM documented the patient left without receiving discharge instructions from the nurse.

Interview on 06/03/35 at 9:53 AM with Physician Staff J revealed he was Patient #2's discharging physician. The patient came in with complaints of nausea/vomiting and severe abdominal pain. The patient was difficult to examine as she would push our hands away when we tried to examine her abdomen. Physician Staff J thought she was doing better and didn't know she continued to have pain at a 9/10. Physician Staff J stated the resident physician had stated the patient was feeling better. The patient requested her IV be removed and left the hospital. She didn't take her discharge paperwork. Physician Staff J stated he didn't get a chance to see her again before she left.

Interview with the Radiology Technician Staff R on 06/09/25 at 4:40 PM revealed Patient #2 was crying and moving a lot during the ultrasound. It was difficult to get good pictures. The patient initially refused transvaginal ultrasound and Radiology Technician Staff R explained the benefits with the patient agreeing to try it. Radiology Technician Staff R got a few images and took a few videos since she wasn't getting good pictures due to the patient moving around in pain and asking Radiology Technician Staff R to stop. Radiology Technician Staff R called the reading room and was transferred to the radiologist. She explained she wasn't getting good pictures to see the ovaries and if this was an ectopic pregnancy. The radiologist stated to attempt to get more pictures, but the patient refused and the exam ended.

Interview with Resident Physician Staff U on 06/10/25 4:00 PM revealed initially they gave Patient #2 MS which helped her pain earlier. Last time Resident Physician Staff U checked on Patient #2 she was getting the IV Tylenol and she verbalized she was a little more comfortable. This is what was reported to Physician Staff J. When Patient #2 was discharged Resident Physician Staff U was off shift.

Interview on 06/26/25 at 3:15 PM with RN Staff S revealed she took care of Patient #2 prior to her leaving. RN Staff S stated she assessed the patient and she was not writhing in the bed in pain. She complained of nausea and vomited on the floor at 7:00 PM. The staff were waiting on a urine sample and Patient #2 wasn't able to urinate. RN Staff S gave the patient options since the urine was needed to rule out a urinary tract infection. The patient asked to be catheterized. After being catheterized the patient called out saying she wanted to leave. She was informed of the need to stay until her urine results were back. RN Staff S let the physician know the patient was waiting for the urine results to leave. Once the discharge was ordered RN Staff S went to the patient's room and the patient had gone. The patient was given pain medication prior to RN Staff S's first seeing the patient. The patient kept saying she was uncomfortable but her vital signs did not indicate she was in pain. By the time RN Staff S went into reassess Patient #2 she was gone.


Review of the facility policy titled "Pain Assessment, Management and Re-assessment" stated the purpose was to provide defined criteria and standardized tools to screen for, assess, and reassess pain. This policy defines severe pain as a number from seven through ten. This policy then refers to Lippincott which instructs staff to document a pain assessment before and after pain medication is given. Pain is assessed upon presentation to the emergency department, at the time of admission and prior to administration of medications. Implement interventions, such as medication administration, emotional support, comfort measures, and complementary and alternative therapies as ordered/indicated based upon the resulting patient reported pain score. This policy further instructs staff to continue pain monitoring and documentation at the intervals outlined in Corporate Clinical Policy "Documentation by Nursing, Acute Care," which states pain should be monitored within one hour after pain intervention.