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Based on medical record review and interview, the facility failed to ensure all records were complete for 3 of 5 Emergency Department records reviewed (#P1, P3, and P4).

Findings included:

1. Review of medical record #P1, the complainant, indicated the patient was triaged in the ED at 7:49 AM on 10/03/12 with the chief complaint, "pt. states he/she developed pain this a.m. after having a bowel movement. Pt. states he/she believes he/she has an umbilical hernia prior to today." The Emergency Physician Record indicated the physician discharged the patient to home at 11:05 AM with a diagnosis of Periumbilical Hernia/UTI [Urinary Tract Infection], but lacked documentation of a condition on discharge on the Emergency Physician Record.

2. Review of medical record #P3 indicated the patient was triaged at 1:13 AM on 10/01/12 with a complaint of right sided abdominal pain, vomiting, and difficulty urination and rated the pain as a 10. The physician wrote to discharge the patient home at 6:55 AM with a clinical impression of abdominal pain, but did not document a condition on discharge on the Emergency Physician Record.

3. Review of medical record #P4 indicated the patient was triaged at 20:54 on 10/04/12 with a complaint of right lower quadrant abdominal pain and episodes of incontinence at night. The physician wrote to discharge the patient home at 2300 with a clinical impression of UTI, but did not document a condition on discharge on the Emergency Physician Record.

4. At 12:20 PM on 11/15/12, the ED manager, staff member #N2, confirmed the lack of the discharge condition by the physician on the Emergency Physician Record for patients #P1, P3, and P4.

Based on policy and procedure review, medical record review, and interview, the facility failed to ensure policies contained provisions for evaluating patients for transportation home upon discharge from the Emergency Department after receiving intravenous (IV) narcotic medication in 3 of 3 records reviewed (#P1, P2, and P3).

Findings included:

1. The facility policy "Emergency Department: Pain Guidelines", last revised 09/11, indicated, "...Re-evaluation of pain will be assessed at most 15-20 minutes after IV (Intravenous) medication, 20- 30 minutes after IM/SC (Intramuscular/Subcutaneous) medication, 45 minutes- 1 hour after PO (Oral) medication and upon dismissal. Re-evaluation will be documented in the EMR (Electronic Medical Record). The Emergency Department physician will be notified of pain upon assessment of the patient and upon re-evaluation of pain. Patients will be given instructions to follow-up with their personal physician or on-call physician if they do not have a physician for continued pain unrelieved by prescribed medications." The policy lacked any provision for evaluating patients for transportation home after IV narcotic medication was received.

2. Review of medical record #P1, the complainant, indicated the patient was triaged in the ED at 7:49 AM on 10/03/12 with the chief complaint, "pt. states he/she developed pain this a.m. after having a bowel movement. Pt. states he/she believes he/she has an umbilical hernia prior to today." The record indicated the patient received 4 milligrams (mg.) of Morphine intravenously (IV) at 8:14 AM, 4 mg. of Ondansetron IV at 8:25 AM, and 1 mg. of Hydromorphone IV at 8:55 AM. The record indicated the patient was discharged to home at 11:38 AM on 10/03/12 after assessing pain and vital signs, but with no evaluation of sedation level or transportation method or needs.

3. Review of medical record #P2 indicated the patient was triaged at 6:17 AM on 10/01/12 with a complaint of right sided abdominal pain, rated at 9, with nausea. The patient received 2 mg. of Morphine IV at 6:47 AM and 4 mg. of Ondansetron IV at 6:49 AM. The record indicated the patient was discharged to home at 9:44 AM on 10/01/12 after assessing pain and vital signs, but with no evaluation of sedation level or transportation method or needs.

4. Review of medical record #P3 indicated the patient was triaged at 1:13 AM on 10/01/12 with a complaint of right sided abdominal pain, vomiting, and difficult urination and rated the pain as a 10. The patient received 4 mg. Ondansetron IV at 2:22 AM, 25 mg. of Demerol IV at 2:24 AM, 50 mg. of Demerol IV at 3:05 AM, 4 mg. of Ondansetron IV at 3:54 AM, 1 mg. of Hydromorphone IV at 3:57 AM, 25 mg. of Phenergan IV at 5:30 AM, 1 mg. Ativan IV at 5:33 AM, and 4 mg. Morphine IV at 6:56 AM. The record indicated the patient was discharged to home at 7:29 AM on 10/01/12 after assessing pain and vital signs, but with no evaluation of sedation level or transportation method or needs.

5. At 12:20 PM on 11/15/12, the ED manager, staff member #N2, confirmed the facility's pain policy did not address patient evaluation for sedation level or method of transportation home after receiving narcotic medication, but indicated this was the standard of practice. He/she indicated this was the only ED pain policy. He/she indicated staff would question the patient prior to the administration of medication as to whether they had a ride since they would not be allowed to drive.

6. At 12:55 PM on 11/15/12, ED staff nurse #N5 was interviewed and indicated he/she would ask a patient if they had a ride before administering narcotic medication, but would take their word for it. He/she indicated it would not usually be documented who the patient went home with unless it was something unusual, such as a taxi.

7. At 1:00 PM on 11/15/12, ED staff nurse #N6 was interviewed and did not indicate asking a patient whether or not they had a ride home prior to administering narcotic medication. When questioned further, he/she indicated staff did not always actually take the patient out of the ED so would not know the method of transportation. He/she indicated the physician usually asked the patient about a ride home before ordering medication. He/she indicated arrangements could be made for a taxi or trolley if a patient was alone and received medication.