HospitalInspections.org

Based on medical records review, policies review and staff interview it was determined the facility staff failed to assess and provide medications according to physician orders and policy for two (#3, #5) of ten sampled patients who received care in the Emergency Department (ED).

Findings include:


1. Patient #3 presented to the ED on 2/28/2014 at 10:27 p.m. with a chief complaint of chest pain, back pain and scapula pain. Triage documentation at 10:37 p.m. noted the vital signs were obtained. Nursing documentation at discharge on 3/1/2014 at 1:40 a.m. noted the vital signs were obtained, approximately 3 hours later. No documentation was found that interim vital signs were taken.

The findings were confirmed by the Chief Nursing Officer and a Registered Nurse on 4/17/2014 at approximately 3:45 p.m.

Review of policy "Assessment and Reassessment in the Emergency Department" #EME 010:2:1 with final approval date 4/5/2013 part B Reassessment line 4 revealed vital signs are to be monitored at least every two hours and/or indicated for patient's condition and length of stay.

2. Patient #5 presented to the ED on 3/4/14 at 9:23 a.m. with a chief complaint of chest and flank pain. ED physician orders at 9:55 a.m. included Aspirin 325 milligrams (mg). The order was initialed by the ED RN with no time documented. Review of pharmacy automated dispensing documentation revealed 162 mg of Aspirin was removed at 11:06 a.m.

Review of policy and procedure "Medication Administration Policy" #RXDNV MM.1.2 dated 3/7/14 Part B section E revealed to verify the medication being administered is the correct medication and correct dose.


The findings were confirmed with the Pre Hospital Coordinator on 4/17/14 at approximately 11:00 a.m. that the wrong dose was administered and there was no documentation of the time the Aspirin was given.