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Based on interview and record review, the hospital failed to ensure a policy and procedure had clear instructions regarding, pediatric PO (by mouth) hydration challenge (the testing tolerance to hold down liquids) without a physician order.

As a result, the nursing staff administered PO hydration to pediatric patients without specifics related to the fluid amount based on age, and weight of the child.

Findings:

On 2/15/17 at 12:55 P.M., a joint interview and record review of the hospital's policy and procedure titled, Standardized Procedures-Emergency Department, was conducted with the Manager of the Emergency Department (MED). The MED reviewed the policy under "Nausea & Vomiting," which directed the nursing staff to "follow Oral Re-Hydration Therapy Nursing Instructions" for children. The MED also reviewed the form titled, ED Oral Re-Hydration Therapy Nursing Instructions, and stated the form was for the patient's parents to understand how to do a PO challenge. The MED further stated oral re-hydration instructions were physician driven (ordered). The MED reviewed the same policy under "Procedure," which indicated, "the following chief complaints may have the following interventions initiated when the ED physician is not available to initiate orders and treatment..." and stated she would need to look into this further.

On 2/15/17 at 1:15 P.M., a follow up interview with the MED was conducted. The MED stated the policy related to re-hydration of children for po challenge was available for the nursing staff to use if a physician was unavailable. The MED further stated there were no written specific instructions based on a child's age/weight for how much fluid to give at one time, and how often for nursing to follow. The MED stated the policy needed to be re-looked at.

On 2/15/17 at 1:25 P.M., a group interview with the QAPI (Quality Assessment and Performance Improvement Program) team, which consisted of the Chief Medical Officer (CMO), Director of Quality (DQ) and the Director of Regulatory (DR) was conducted. The CMO, DQ, and DR all stated the policy related to re-hydration needed specific protocols for the nursing staff to follow.

Based on interview, medical record and document review, the hospital failed to ensure that the Emergency Department (ED) staff implemented its policy regarding pain assessment by failing to document a follow up pain assessment following an intervention for 1 out of 30 (11) patient charts reviewed.

As a result, Patient 11's medical record was not complete regarding the pain reassessment following an intervention.

Findings:

On 2/14/17 at 3:30 P.M., a review of patient 11's medical record was conducted. Per the face sheet, dated 11/14/16, patient 11 was a 9 year old male brought to the ED on 11/14/16 at 7:42 A.M. with a chief complaint of right thumb pain. Per Nursing triage documentation dated 11/14/16 at 7:59 A.M., Triage RN 1 indicated that patient 11 complained 9/10 right thumb pain. Per the ED note dated 11/14/16 at 9:23 A.M. the Physician Assistant (PA 1) indicated that Patient 11's pain was 9 out of 10, sharp with no radiation or alleviating factors. The note further indicated that Patient 11's x-ray indicated a right thumb fracture and a right thumb splint was applied at 9:29 A.M. The ED note specified that Patient 11 was discharged home on 11/14/16 at 9:30 A.M., with instructions to follow up with orthopedics and to take Tylenol and Motrin over the counter for discomfort. There was no documentation of pain reassessment following the application of the splint prior to Patient 11's discharge.

A review of the hospital's policy and procedure titled "Assessment of the Pediatric Patient in the Emergency Department," dated 8/2014, was reviewed on 2/15/17 at 8:55 A.M. The policy specified that "pediatric patients are assessed by the ED nurse upon arrival. Special considerations may include: Pain... Reassessment as needed post interventions or for change in patient status."

An interview with the ED Medical Director (EDMD) was conducted on 2/15/17 at 10:15 A.M. The EDMD stated,regarding patient 11's initial pain assessment documentation level of 9/10 and the lack of documentation of a pain reassessment prior to Patient 11's discharge, did not meet the Hospital's ED standards of care. The EDMD acknowledged there was an opportunity for improvement regarding documentation of pain reassessment for Patient 11.

An interview with the Manager of the ED (MED) was conducted on 2/15/17 at 12:54 P.M. The MED stated that Patient 11 should have had a pain reassessment documented in accordance with the Hospital's Policy and Procedure.

Based on interview and record review the facility failed to ensure a pediatric pain assessment was completed upon admission in the Emergency Department (ED) for 2 of 30 sampled patients (19, 23).

As a result, Patients' 19 and 23's records were not complete regarding the pediatric pain assessment.

Findings:

1. On 2/14/17 at 3:30 P.M., a review of Patient 19's medical record was conducted. Per the Face Sheet, Patient 19 was a 6 year old female brought to the ED on 11/14/16 at 2:54 A.M. Per the RN Triage Note dated 11/14/16 at 3:27 P.M., the Triage Registered Nurse (TRN 2) documented Patient 19 complained of redness and pain to the left eye. The note further indicated under medical history diagnoses, "(active) eye pain". There was no nursing documentation of pain assessment or pain level regarding Patient 19's left eye.

The hospital's policy and procedure titled, Assessment of the Pediatric Patient in the Emergency Department, dated 8/2014, was reviewed on 2/15/17 at 8:55 A.M. The policy specified, "pediatric patients are assessed by the ED nurse upon arrival. Special considerations may include: Pain: FLACC (Face Legs Activity Cry and Consolability ), RIPS ( Riley Infant Pain Scale) for pre-verbal children."

An interview with the ED Medical Director (EDMD) was conducted on 2/15/17 at 10:15 A.M. The EDMD stated Patient 19's presentation with a complaint of left Eyelid pain and no nursing documentation of pain assessment/level of pain did not meet the Hospital's ED standards of care. The EDMD acknowledged there was an opportunity for improvement regarding documentation of pain assessment regarding Patient 19's left eye pain.

An interview with the Manager of the Emergency Department (MED) was conducted on 2/15/17 at 12:54 P.M. MED stated the nurse should have assessed Patient 19 for pain upon arrival to the ED and documented the assessment in accordance with the Hospital's policy and procedure.


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2. Patient 23's record was reviewed on 2/14/17 at 11:37 A.M. Patient 23 was a 4-year-old male admitted to the Emergency Department (ED) on 1/1/17, with a diagnosis of right ear pain, per the Face Sheet.

According to Patient 23's ED Pediatric Assessment intake record, dated 1/1/17 at 3 A.M., the nurse documented Patient 23 had right ear pain for one week. The Triage Registered Nurse (TRN 3) initial pain assessment for Patient 23 was not completed.

On 2/15/17 at 10 A.M., during an interview, the Emergency Department Medical Director (EDMD) stated a pain assessment was a nursing function. EDMD further stated the expectation was for nursing staff to assess and document the patient's pain.

On 2/15/17 at 10:44 A.M., a joint interview and review of Resident 23's record was conducted with the Director of Regulatory (DR). The DR stated, "No pain assessment was documented in the medical record."

On 2/15/17 at 12:47 P.M., an interview with the Manager of Emergency Department (MED) was conducted. The MED stated her expectation was the nursing staff should assess pediatric patients for pain at the time of intake. The MED further stated, at intake, the nurse should complete the pain assessment and document it in the medical record.

The hospital's policy and procedure, titled Hospital A Healthcare Emergency Department Guidelines of Care, dated 2016, "...2. Complete pediatric triage and bedside assessment screen on patients less than 14 years of age... E. Pediatric pain assessment will be completed..."