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Based on interview and record review, the facility failed to ensure two (2) of thirty-one sampled patients (Patient 20 and Patient 26) were provided information regarding and/or verified information for having advance directives according to facility's policy and procedure for Advance Directives.

This deficient practice had the potential for patient's wishes regarding care, not being followed, should the patient become incapacitated (impaired to make decision) and unable to provide consent for care.

Findings:

a. A review of Patient 20's Face Sheet, dated 1/8/2023, indicated patient had a chief complaint of flu-like symptoms.

On 8/17/2023, at 11:30 AM, during concurrent interview with Emergency Department Manager (ED Mgr.) and record review of Patient 20's medical records, ED Mgr. stated on review of Patient 20's medical records, the facility did not assess for or verify Patient 1 had an advance directive.

b. A review of Patient 26's Face Sheet, dated 1/1/2023, indicated patient had a chief complaint of nausea, vomiting, and dehydration (body does not have as much water and fluids as it needs).

On 8/16/2023, at 11:02 AM, during concurrent interview with ED Director (ED Dir.) and record review of Patient 26's medical records, ED Dir. stated on review of Patient 26's medical records, the facility did not assess for and/or verify Patient 7 had an advance directive.

A review of facility's policy, Advance Directives, dated 11/03/2022, indicated the following:
a. Admitting department will provide patient with written information regarding advance health care directives.
b. Registered Nurse (RN) will ask patient if the patient has an advance directive and will confirm that the patient's current version of the advance directive was scanned into patient's medical records.
c. RN will ask patient if he/she received advance directive information from admitting department.
d. RN will ask patient, who does not have an advance directive, if they would like to identify another person who knows their wishes related to health care and document that information in patient's medical records.
e. RN will communicate the existence and substance of an advance directive to the patient's health care provider and team.

Based on observation, interview, and record review, the facility failed to ensure that the Condition of Participation for Nursing Services was met as evidenced by:

1. The facility nursing staff failed to reassess patient's complaint of pain and evaluate effectiveness of administered pain medication for two (2) of thirty-three sampled patients (Patient 26 and 29) according to facility policies and procedures for pain management. Patients 26 and 29 had complaints of pain and were given Morphine (pain medication) for pain. (Refer to A - 395).

2. The facility emergency room nursing staff failed to follow policy and procedure for reassessment of patients' vital signs (assessment of essential body functions that included heart rate, breathing rate, temperature, and blood pressure) every two (2) hours in the Emergency Department (ED) for four (4) out of thirty-three patients sampled (Patient 1, 3, 8, and 19). (Refer to A - 398).

3. The facility emergency room nursing staff failed to assess and/or reassess complaint of pain for eight (8) of thirty-three sampled patients (Patient 1, 4, 6, 20, 23, 24, 27, and 28) according to facility policies and procedures for pain management. (Refer to A - 398).

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care by the nursing staff.

Based on interview and record review, the facility nursing staff failed to reassess patient's complaint of pain and evaluate effectiveness of administered pain medication for two (2) of thirty-one sampled patients (Patient 26 and 29) according to facility policies and procedures for pain management. Patients 26 and 29 had complaints of pain and were given Morphine (pain medication) for pain.

This deficient practice resulted in Patient 26 and 29 not receiving proper pain management and had the potential for other patients in the emergency department not receiving proper care for pain.

Findings:

1. A review of Patient 26's face sheet (patient information record), dated 1/1/2023, indicated under visit information, Patient 26 had a chief complaint of nausea and vomiting.

On 8/16/2023, at 11:02 AM, during concurrent interview with Emergency Department (ED) Director (Dir.), and record review of Patient 26's Patient Care Timeline, dated 1/1/2023 and timed at 14:22 [2:22 p.m.] to 1/1/2023 and timed at 14:32 [2:32 p.m.], ED Dir. stated during patient's triage on 1/1/2023, at 2:28 PM, Patient 26 complained of severe pain with a pain score of 10 out of 10 (pain scale in which zero [0] was considered no pain; 1 to 3 was mild pain; 4 to 6 was moderate pain; and 7 to 10 was severe pain).

On 8/16/2023, at 11:02 AM, during concurrent interview with ED Dir, and record review of Patient 26's Flowsheet, ED Dir. stated Patient 26 complained of pain on 1/1/2023, at 5 PM, with a pain score of 7 of 10, which was severe pain.

On 8/16/2023, at 11:02 AM, during concurrent interview with ED Dir, and record review of Patient 26's Emergency Department Encounter, dated 1/1/2023, The record indicated Patient 26 received Morphine 4 milligram (mg, unit of measurement) intravenous (IV, into the vein) on 1/1/2023 at 16:06 (4:06 p.m.). ED Dir. stated Patient 26 received pain medication and Patient 26's pain level was not reassessed after receiving Morphine for pain. ED Dir stated Patient 26's should have been reassessed for pain prior to and after administration of pain medication.

2. A review of Patient 29's face sheet, dated 1/7/23, indicated under visit information, Patient 29's chief complaint was trauma (a terrible event like an accident such as a fall) after ground level fall.

A review of Patient 29's Emergency Department Encounter, dated 1/7/2023, indicated under ED course, discussion, and medical decision making, Patient 29 was given Morphine (pain medication) 2 mg IV.

On 8/16/23, at 3:58 PM, during concurrent interview with ED Dir., and record review of Patient 29's Patient Care Timeline dated 1/7/2023 and timed at 18:11 [6: 11 p.m.] to 1/7/2023 at 18:20 [6:20 p.m.], ED Dir. stated Patient 29 was brought into the facility by ambulance on 1/7/23, at 6:11 PM, and placed in the trauma room, with initial vital signs done with a pain score of 10 of 10. ED Dir. stated Patient 29 received pain medication, on 1/7/23 at 7:46 PM. ED Dir. stated Patient 29 was not reassessed for pain, on 1/7/23 from 7:03 PM to 10:24 PM, even after administration of pain medication to evaluate effectiveness of pain medication for 10 out of 10 level of pain.

A review of facility's policy, Assessment of Patient, dated 10/1/2022, indicated the following that upon admits, discharge, or transfer out of ED, document a final assessment and complete set of vital signs, including heart rate, temperature, blood pressure, pain scale, and oxygen saturation (measurement of oxygen level in the blood), within 30 minutes.

A review of facility's policy, Admission/Transfer/Discharge and Scope of Service in the Emergency Department (ED), dated 5/3/2021, indicated the following:

a. Upon discharge or transfer out of the ED, a final assessment, and a complete set of vital signs (heart rate, respiratory rate, temperature, blood pressure, pain scale, oxygen saturation) are required within 30 minutes of leaving the ED.

b. Pain status must be assessed and documented using a 0 to 10 number scale.

A review of facility's policy, Pain Assessment and Management, dated 9/29/2022, indicated the following:

a. The physician and registered nurse (RN) are responsible for the assessment and reassessment of pain and the effectiveness of interventions.

b. The physician is responsible for the ordering of pharmacologic (relating to drugs and/or medication) agents.

c. The RN is responsible for the administration and monitoring of pharmacologic agents.

d. The identification of patients experiencing pain/discomfort and its management are contingent upon appropriate initial and ongoing pain assessment.

e. On initial report of pain, assess the patient to collect additional information to identify/describe the pain, including location, nature of, tolerance to, and acceptable intensity of pain.

f. Reassess for the presence of pain and the effectiveness of interventions before and after each pharmacologic and non-pharmacologic intervention, within 60 minutes.

e. Pain assessment, intervention, and patient's response to treatment are documented in the patient's medical record.

Based on observation, interview, and record review, the facility emergency room nursing staff failed to:

1. Reassessment of patients' vital signs (assessment of essential body functions that included heart rate, breathing rate, temperature, and blood pressure) every two (2) hours in the Emergency Department (ED) for four (4) out of thirty-three patients sampled (Patient 1, 3, 8, and 19) according to facility policy and procedure for assessment and reassessment

This deficient practice had the potential to compromise patients' safety by preventing early identification of worsening signs and symptoms or life-threatening conditions to delivery of timely interventions.

2. Assess and/or reassess complaint of pain for eight (8) of thirty-one sampled patients (Patient 1, 4, 6, 20, 23, 24, 27, and 28) according to facility policies and procedures for pain management.

This deficient practice resulted in Patient 1, 4, 6, 20, 23, 24, 27, and 28) not receiving care proper pain management and had the potential for other patients in the emergency department not receiving proper care for pain.


Findings:

1.a A review of Patient 1's face sheet (Patient information record), indicated Patient 1 presented to the facility's emergency department (ED), on 1/5/23 at 12:40 AM with a chief complaint of a urinary catheter (a tube placed in the body to drain and collect urine from the bladder) problem.

A review of Patient 1's ED Provider Notes, dated 1/5/23 at 12:47 AM, indicated Patient 1 arrived in the ED via paramedics. Patient 1's medical history included being diagnosed with prostate cancer (a form of cancer that begins in the gland cells of the male reproductive system) and undergoing radiation therapy (treatment uses beams of intense energy to kill cancer cells).

During a concurrent interview with the Manager of Quality and Patient Safety (MQPS) and emergency department Registered Nurse 2 (RN 2), and record review of Patient 1's Patient Care Timeline, dated from 1/4/23 at 9:22 PM to 1/5/23 at 2:09 AM, on 8/15/23 at 9:35 AM, RN 2 stated on 1/5/23 at 8:00 AM, Patient 1's heart rate increased to 131 beats per minute (a normal resting heart rate for adults ranges from 60 to 100 beats per minute). RN2 stated Patient 1's Emergency Severity Index (ESI, five - level classification assessment for the level of care provided from level 1 (most urgent) to level 5 (least urgent), was changed from ESI 4 to ESI 3 on 1/5/23 at 11:21 PM. RN 2 stated Patient 1's first vitals were taken on 1/5/23 at 9:26 PM. RN 2 stated the second vital signs were taken 3 hours and 25 minutes later, on 1/6/23 at 12:51 AM. RN 2 stated Patient 1's vital signs were not taken every two hours.

1. b. A review of Patient 3's face sheet indicated Patient 3 was presented to the facility ED ,on 1/9/23 at 3:03 AM, with chief of complaint chills, fatigue, and shortness of breath.

A review of Patient 3's ED Provider Notes, dated November 1/9/23 at 3:39 AM, indicated, Patient 3 had chief of complaint includes chest pain last week but had resolved, 1.5 weeks with fatigue and vomiting, fever of 101 degrees Fahrenheit (F, unit of measurement for temperature, normal level range between 97 F to 99 F ), difficulties breathing with increase shortness of breath. The notes also indicated, electrocardiogram (EKG, records the electrical signal of the heart to check heart conditions), results include tachycardia (an increased heart rate). Patient 3's heart rate was 108 beat per minute (a normal resting heart rate for adults ranges from 60 to 100 beats per minute), right bundle branch block (there's a delay or blockage along the pathway that electrical impulses travel to make the heartbeat for the right side of the heart), EKG was abnormal as interpreted by the provider.

During a concurrent interview with the Manager of Quality and Patient Safety (MQPS) and emergency department Registered Nurse 2 (RN 2), and record review of Patient 3's Patient Care, dated from 1/8/23 at 5:43 PM to 1/8/23 at 11:02 AM, on 8/15/23 at 10:10 AM, RN 2 stated Patient 3 was assigned an Emergency Severity Index (ESI, five - level classification assessment for the level of care provided from level 1 (most urgent) to level 5 (least urgent), of 3, and vital signs should be taken at a minimum every two hours. RN 2 stated Patient 3's initial vital signs taken at 6:00 PM indicated high blood pressure at 202/77 millimeter of mercury (mmHg, unit of measurement) (a normal blood pressure [BP] range 90/60 millimeter of mercury [mmHg] to 120/ 80 mmHg). Patient 3 had a respiratory rate of 40 breaths per minute (normal respiratory rate for adult at rest rang from twelve to eighteen breaths per minute). RN2 stated the next vital signs taken for Patient 3 was at 3:16 AM, nine hours and sixteen minutes after the initial vital signs were taken.

1. c. A review of Patient 8's face sheet, indicated Patient 8 presented to the facility's ED, on 8/14/23 at 2:12 PM with complaint of chest pain.

A review of Patient 8's ED Provider Notes, dated 8/14/23 at 2:29 AM, indicated, Patient 8 presented to the ED with a complaint of left-sided chest pain, which began this morning. The notes indicated Patient also reported generalized weakness and fatigue.

During a concurrent observation and interview with the ED clinical operations manager (ED Mgr.) in the ED internal waiting room (IWR), on 8/14/23 at 11:17 AM, Patient 8 was observed sitting in a wheelchair besides three other patients in the IWR area. Patient 8 was slouched on a wheelchair. Patient 8 stated he came in on his own, and he was not accompanied by family. Patient 8 stated he had been waiting for 15 minutes in this waiting area. Patient 8 stated he was waiting for the nurse. ED Manager stated, "Patients waiting in this area are stable patients waiting to get blood drawn or test results read."

During a concurrent interview with the MQPS and RN2, and record review of Patient 8's Patient Care Timeline, dated 8/14/23 at 10:11 AM to 8/14/23 at 5:59 PM, on 8/15/23 at 3:43 PM, RN 2 stated Patient 8's initial vital signs were taken on 8/14/23 at 10:23 AM. RN 2 stated Patient 8 was assigned ESI level 2. RN 2 stated for Patient 8 had chest pain and vital signs should be taken a minimum every two hours. RN 2 stated the second vital signs were taken, on 8/14/23 at 2:46 PM, four hours and three minutes after the initial vital signs.

1. d. A review of Patient 19's ED Provider Notes, dated November 8/14/23 at 8:03 AM, indicated, Patient 19's chief complaints were leg pain, abdominal pain, vomiting and increased bowel sounds.

During a concurrent interview with the MQPS and RN2, and record review of Patient Care Timeline, dated from 8/14/23 at 10:41 AM to 8/14 at 9:29 PM, on 8/15/23 at 3:43 PM, RN 2 stated the initial vitals indicated Patient 19's blood pressure was elevated at 184/91 mmHg (a normal blood pressure range 90/60 mmHg to 120/ 80 mmHg) was taken at 11:27 AM ). RN 2 stated Patient 19's vital signs were not reassessed until 8/14/23 at 7:53 PM, eight hours and twenty-six minutes after the initial vital signs were taken. Patient 19's blood pressure remained elevated at 163/90 mmHg at 7:53 p.m. RN 2 stated Patient 19's vital should be reassessed at a minimum every two hours.

A review of facility's Assessment/Reassessment Grid for ED, undated, indicated in the ED, BP, pulse, respiratory rate, temperature was done, "At triage or upon arrival ...reassess q (every) 2 hrs. (hours) in ED."

2. a. A review of Patient 1's face sheet (Patient information record), indicated Patient 1 presented to the facility's emergency department (ED), on 1/5/23 at 12:40 AM with a chief complaint of a urinary catheter (a tube placed in the body to drain and collect urine from the bladder) problem.

A review of Patient 1's ED Provider Notes, dated 1/5/23 at 12:47 AM, indicated Patient 1 arrived in the ED via paramedics. Patient 1's medical history included being diagnosed with prostate cancer (a form of cancer that begins in the gland cells of the male reproductive system) and undergoing radiation therapy (treatment uses beams of intense energy to kill cancer cells).

During a concurrent interview with the Manager of Quality and Patient Safety (MQPS) and emergency department Registered Nurse 2 (RN 2), and record review of Patient 1's Patient Care Timeline, dated from 1/4/23 at 9:22 PM to 1/5/23 at 2:09 AM, on 8/15/23 at 9:35 AM, RN 2 stated on 1/5/23 at 8:00 AM, Patient 1's heart rate increased to 131 beats per minute (a normal resting heart rate for adults ranges from 60 to 100 beats per minute). RN2 stated Patient 1's Emergency Severity Index (ESI, five - level classification assessment for the level of care provided from level 1 (most urgent) to level 5 (least urgent), was changed from ESI 4 to ESI 3 on 1/5/23 at 11:21 PM. RN2 stated the first vital signs were taken on 1/5/23 at 9:26 PM and Patient 1 did not have a pain assessment. RN 2 stated the second vital sign was taken on 1/6/23 at 12:51 AM, and Patient 1 did not have a pain assessment.

2. b. A review of Patient 4's face sheet indicated Patient 4 presented to the facility's emergency department (ED), on 1/8/23 at 11:55 AM with a chief complaint of high blood pressure and nausea.

A review of Patient 4's ED Provider Notes, dated 1/8/23 at 11:19 AM, indicated that Patient 4's medical history included a brain tumor (a growth of cells in the brain) status post-resection (surgical partial removal of the tumor). The notes indicated Patient 4 had presented to the ED with high blood pressure, generalized headache, and dizziness for the past week. The note indicated that Patient 4 stated that whenever his blood pressure was elevated, had headaches, felt dizzy, and started seeing spots in his vision.

During a concurrent interview with the MQPS and RN 2 and record review of Patient Care Timeline was reviewed,
dated 1/7/23 at 2:55 PM to 1/8/23 at 11:02 AM, on 8/15/23 at 10:27 AM, the record indicated, on 1/8/23 at 6:34 PM, Patient 4 rated his pain at 9 out of 10 on a numeric pain scale (zero was considered no pain; 1 to 3 was mild pain; 4 to 6 was moderate pain; and 7 to 10 was severe pain). RN 2 confirmed the second vitals assessment completed on 1/8/23 at 8:52 PM did not have a pain reassessment.

2. c. A review of Patient 6's face sheet indicated Patient 6 presented to the facility's ED, on 1/8/23 at 9:41 AM with a chief complaint of MVA (motor vehicle accident) with back pain.

A review of Resident 6's Trauma History and Physical (Trauma H&P), dated 1/8/23 at 10:15 PM, indicated Patient 6 was brought into ED in a private vehicle 3 hours after the MVA complaining of pain.

During a concurrent interview with the MQPS and RN 2 and record review of Patient 6's Patient Care Timeline, dated 1/8/23 at 8:29 PM to 1/8/23 at 10:30 PM, on 8/15/23 at 11:10 AM with RN 2 stated Patient 6's initial pain assessment indicated Patient 6 had a pain level 7 out of 10 (the numeric pain scale indicates 7 to 10 was severe pain) at 9:03 PM. RN 2 stated the record had no documentation of Patient 6's pain location or duration (how long) of the pain. RN 2 stated it (assessment of pain) was important to have the location and duration of pain documented, as it will help staff plan Patient 6's care.

During a concurrent interview with RN 2 and record review of Patient 6's flowsheet (Patient assessment record of vital signs and pain), on 8/15/23 at 11:10 AM, Patient 6's flowsheet indicated vitals were taken again on 1/8/23 at 9:59 AM, 10:29 AM, 10:59 AM, and 11:29 AM, and Patient 6 had no pain assessment. The flowsheet indicated the only other pain assessment documented throughout the Patient 6's ED visit was upon discharge at 12:59, which indicated the patient denies pain.

2. d. A review of Patient 20's face sheet, dated 1/8/2023, indicated under visit information, Patient 20 had a chief complaint of flu-like symptoms (symptoms include fever, cough, congestion, body aches, headache, fatigue, and sore throat).

On 8/15/2023, at 8:45 AM, during concurrent interview with emergency department (ED) manager (ED Mgr.), and record review of Patient 20's ED records, ED Mgr. stated during patient's triage on 1/8/2023, at 00:50 AM, Patient 20 was not assessed for pain. ED Mgr. stated Patient 20 should have been assessed for pain during triage (a system of sorting patients according to need).

2. e. A review of Patient 23's face sheet, dated 1/9/2023, indicated under visit information, Patient 23 was sent to ED from urgent care (walk-in clinic focused on the delivery of medical care for minor illnesses and injuries) clinic.

On 8/16/2023, at 9:20 AM, during concurrent interview with ED director (ED Dir.) and record review of Patient 23's Patient Care Timeline, dated 1/8/2023 and time at 12:30 p.m. to 1/8/2023 and time at 12:34 p.m., ED Dir. stated Patient 23 complained of pain and discomfort, at 12:30 PM, and rated pain at 8 of 10 (pain scale that grades pain levels from 0 (No pain), 1,2, and 3 (Mild), 4,5, and 6 (Moderate), 7,8, and 9 (Severe) to 10 (Worst Pain Possible), which is severe pain.

On 8/16/2023, at 9:20 AM, during concurrent interview with ED director (ED Dir.) and record review of patient's ED physician notes, dated 1/9/2023, ED Dir. stated ED physician (MD 1) documented Patient 23 had pain score of 8 of 10 pain and complained of pain and discomfort - flank (the fleshy part of the side between the ribs and the hip) pain. ED Dir. stated there was no physician orders for pain medication. ED Dir. stated Patient 23 was not reassessed for pain.

2. f. A review of Patient 24's face sheet, dated 1/1/2023, indicated under visit information, Patient 24 had a chief complaint of abdominal pain.

A review of Patient 24's Patient Care Timeline dated 1/1/2023 and timed at 00:46 a.m. to 1/1/2023 and timed at 00:57, indicated Patient 24 was 10 weeks pregnant with abdominal pain and was bleeding.

On 8/16/2023, at 9:55 AM, during concurrent interview with ED Dir. and record review of Patient 24's ED records, ED Dir. stated Patient 24 was triaged on 1/1/2023, at 00:54 AM, and complained of pain/discomfort. ED Dir. stated there was no pain score documented and had no pain medication order.

2. g. A review of Patient 27's face sheet , dated 1/3/2023, indicated under visit information, Patient 27 had a chief complaint of suicidal ideation (thoughts of harming self).

On 8/16/2023, at 1:52 PM, during concurrent interview with ED Dir., and record review of Patient 27's Patient Care Timeline dated 1/3/2023 and timed at 22:49 [10:49 p.m.] to 1/3/2023 and timed at 23:43 [11:23 p.m.], ED Dir. stated Patient 27 was triaged at 1/3/2023, at 11:38 PM. ED Dir. stated Patient 27 had complained of pain with a pain score of 10 of pain, which was severe pain.

On 8/16/2023, at 1:52 PM, during concurrent interview with ED Dir., and record review of Patient 27's ED Provider Notes, dated 1/4/2023 time at 1:47 a.m., ED Dir. stated ED physician documented during physical examination, Patient 27 complained of pain/discomfort with a pain score of 10 of 10 and had no orders for pain medication.

2. h. A review of Patient 28's face sheet, dated 1/7/2023, indicated under visit information Patient 28's chief complaint was weakness.

On 8/16/23, at 3:22 PM, during concurrent interview with ED Dir., and record review of Patient 28's ED records, ED Dir. stated patient's chief complaint was updated and indicated patient had a recent history of tripping, falling, and hitting his left elbow, after a dizzy spell. ED Dir. stated Patient 28 was triaged at 1/6/23, at 1:35 PM, without a pain assessment done throughout patient's ED visit, until 1/7/23, at 11:59 AM, when patient left the facility against medical advice.

A review of facility's policy, Assessment of Patient, dated 10/1/2022, indicated the following:

a. Triage patients within 15 minutes of arrival and placement in the ED.

b. Initial assessment by a registered nurse (RN) is done in the main ED with a complete review of systems.

c. Upon admits, discharge, or transfer out of ED, document a final assessment and complete set of vital signs, including heart rate, temperature, blood pressure, pain scale, and oxygen saturation (measurement of oxygen level in the blood), within 30 minutes.

A review of facility's policy, Admission/Transfer/Discharge and Scope of Service in the Emergency Department (ED), dated 5/3/2021, indicated the following:

a. Upon discharge or transfer out of the ED, a final assessment, and a complete set of vital signs (heart rate, respiratory rate, temperature, blood pressure, pain scale, oxygen saturation) are required within 30 minutes of leaving the ED.

b. Pain status must be assessed and documented using a 0 to 10 number scale.

A review of facility's policy, Pain Assessment and Management, dated 9/29/2022, indicated the following:

a. The physician and registered nurse (RN) are responsible for the assessment and reassessment of pain and the effectiveness of interventions.

b. The physician is responsible for the ordering of pharmacologic agents.

c. The RN is responsible for the administration and monitoring of pharmacologic (relating to drugs and/or medication) agents.

d. The identification of patients experiencing pain/discomfort and its management are contingent upon appropriate initial and ongoing pain assessment.

e. On initial report of pain, assess the patient to collect additional information to identify/describe the pain, including location, nature of, tolerance to, and acceptable intensity of pain.

f. Reassess for the presence of pain and the effectiveness of interventions before and after each pharmacologic and non-pharmacologic intervention, within 60 minutes.

e. Pain assessment, intervention, and patient's response to treatment are documented in the patient's medical record.