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Tag No.: A0395
Based on medical record reviews, interviews, and policy review, for one of ten patients admitted to the ED (Patient #1 and #2), the facility failed to ensure that the RN conducted a comprehensive focused assessment and/or that the patient's pain was addressed. The findings include:
Patient #1 arrived at the ED on 10/24/17 at 12:47 AM with a chief complaint of gluteal abscess and was assigned to a room at 1:05 AM. The triage assessment by RN #1 on 10/24/17 at 1:34 AM identified that the Patient was an acuity triage level "4" and rated gluteal pain as a 10 on a scale of 0-10 (with 10 being the worst possible pain). At 1:48 AM, RN #1 documented that the patient stated the lower gluteal abscess had been present for one week and had suddenly increased in size and pain. The patient was observed resting comfortably on the stretcher with family at bedside. At 1:49 AM, the patient's vital signs were documented as follows: blood pressure 134/79, pulse rate 70, respirations 17, oxygen saturation 98% on room air, and temperature 98.4 degrees Fahrenheit.
Review of the clinical record identified that at 3:59 AM, the patient wishes to leave without treatment, stable at time of departure, documented vital signs at 4:00 AM, patient discharged at 4:13 AM.
The clinical record failed to reflect that the RN assessed the patient's abscess inclusive of location, size, color and the presence/absence of drainage.
Documentation was lacking that RN #1 had informed MD #3 of the Patient's pain and/or that pain interventions had been tried. A reassessment of the Patient's pain level was not documented prior to discharge.
Interview with Person #1 on 12/12/17 at 1:25 PM indicated that RN #1 did not examine the area of the abscess on 10/24/17 and that they left the hospital because the Patient was not evaluated by the MD for 4 hours and was not offered analgesics for the intense pain.
Interview with RN #1 on 12/1/17 at 10:52 AM noted that she recalled the Patient who informed her that the abscess was on his/her right side and RN #1 stated she did not assess the abscess. RN #1 stated although she had not documented pain interventions in the Patient's medical record, she reported the Patient's pain level to MD #1 and the Patient refused ice that she had offered to help decrease the pain.
Interview with the ED Manager on 12/7/17 at 9:35 AM identified that she would expect RN #1 to assess the patient's abscess and document this in the Patient's record.
Interview with MD #3 on 12/12/17 at 9:34 AM identified that he would order either a pill or injection for a patient's pain depending on information from the RN and would do so even if he had not yet seen the patient.
The facility vital sign and pain guidelines policy identified that a pain level over 3 will be reported to a provider and documented as such. The policy further identified that patients who report an unacceptable level of pain will be offered an intervention to reduce the pain.
The facility ED assessment policy identified that triage levels 1, 2 and 3 will receive a comprehensive system review. Although the policy did not direct the assessment required for triage acuity levels 4 and 5, interview with RN #2 (Regional Manager) on 12/12/17 at 2:53 PM indicated that it was facility practice for nursing to conduct a focused assessment for triage levels 4 and 5 patients based on their complaint.
b. Patient #2 was admitted to the ED on 10/24/17 at 12:37 AM with a chief complaint of abdominal pain. The RN triage assessment dated 10/24/17 at 1:20 AM identified that the Patient rated stomach pain as an 8 on a 0-10 pain scale, rated headache pain as a 7/10 since 10/23/17, and was designated a triage acuity level of "3". The record lacked evidence that the RN notified the physician of the patient's pain. The RN assessment at 3:25 AM identified that the Patient was waiting to be seen by the MD and rated pain level of 8/10. The record failed to note that the physician was made aware of the patient's pain and that interventions to reduce the pain were offered in accordance with facility policy.
Patient #2 left without being seen by the MD at 5:04 AM (4 hours and 27 minutes after registration). Review of the Patient's record with the Quality Specialist on 12/12/17 at 2:58 PM noted that she would check with RN #2 to see if pain interventions might be documented elsewhere in the Patient's medical record. Additional documentation could not be provided.
Tag No.: A1112
Based on medical record reviews, review of facility documentation, review of ED staffing schedules and interviews, the facility failed to ensure that measures were instituted to ensure timely provider evaluations in the (ED) emergency department. The finding includes:
Patient #1 was admitted to the ED on 10/24/17 at 12:47 AM with a chief complaint of gluteal abscess, was triaged as an acuity level "4" (levels 1-5 with 1 being the most severe) and had a reported pain level of 10/10. RN documentation dated 10/24/17 noted that Patient #1 LWBS (left without being seen) 3 hours 13 minutes after registration at 4:00 AM.
Patient #2 was admitted to the ED on 10/24/17 at 12:37 AM with a chief complaint of abdominal pain level 8/10 and was triaged as an acuity level 3. RN documentation dated 10/24/17 identified that the Patient LWBS 4 hours and 27 minutes after registration at 5:04 AM.
The ED log dated 10/24/17 indicated that 7 other patients had arrived at the ED on 10/24/17 from 12:04 AM to 12:39 AM with triage acuity levels of 2, 3, 3, 2, 4, 3, and 1 respectively. The Patient (acuity level 1) that arrived at 12:39 AM and just prior to Patient #1, was in cardiac arrest and required immediate care. Subsequent to Patient #1's arrival at 12:47 AM, 10 patients arrived to the ED from 1:23 AM to 3:46 AM that were triaged at a level 2 or 3.
Patient #3's record indicated that the Patient had arrived to the ED on 10/24/17 at 2:52 AM with a chief complaint of flank pain, was a level 3 triage and also LWBS at 5:28 AM.
Physician staffing schedules noted that MD #3 worked 10:00 PM to 7:00 AM on 10/23/17 into 10/24/17, MD #2 worked until 1 AM on 10/24/17 and PA #1 worked until 2:00 AM on 10/24/17.
Interview with the ED Director, MD #1 on 12/7/17 at 11:19 AM indicated that Mondays were very busy, if the ED MD was behind, the MD could call him and he would attempt to remedy the situation. He further identified that the median door to MD time is 40 minutes and a door to MD time of 3 hours was an outlier, happens occasionally and should not happen. Interview with MD #3 on 12/12/17 at 9:34 AM noted that despite registration time, he would see patients with a lower triage level first and could call the Surgical Resident or the Hospitalist to assist him in the ED if necessary.
Although the facility followed their Practitioner ED staffing plan, alternative measures were not instituted to help to remediate the delay in medical screening examinations on 10/24/17.