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Based on review of hospital policies and procedures, review of medical records and staff interviews, the nursing staff failed to evaluate and supervise the nursing care of patients by failing to reassess for pain for 3 of 3 emergency department patients who received pain medication (#8, #7 and #5) and failing to reassess a patient's blood pressure for 1 of 1 emergency department patients with elevated blood pressure (#8).

The findings include:

Review of the hospital's policy, "Pain Assessment and Management", revised 11/21/2012, revealed, "...B. Pain Re-assessments 4. Reassessment after a pharmacological intervention occurs within 60-minutes...".

Review of the hospital's policy, "Assessment/Reassessment", revised 07/2009, revealed, "I. SCOPE/PURPOSE/POLICY STATEMENT Patients are assessed to determine the type of care required to meet their initial needs; they are continually reassessed to ensure that the care rendered corresponds to their changing needs. ...ADDENDUM A. ...Between Re-assessments Time Frame...Emergency Services Minimum of every 4 hours, or as patient condition warrants... Scope of Re-assessment Responses to medications, treatments, activities...".

1. Closed ED (emergency department) record review of Patient #8 revealed a 57 year-old male who presented to the ED on 05/02/2013 at 1109 with chief complaint of "kidney stone pain and vomiting". Record review revealed the patient was triaged at 1118 by RN #1. Record review revealed documentation by RN #1 that Patient #8's pain level was 10 of 10, on a scale of 1 to 10, with 10 being the most severe pain. Further documentation by RN #1 revealed Patient #8's blood pressure was 170/95 (elevated). Record review revealed a physician's order at 1130 for Dilaudid (narcotic pain medication) 1 mg (milligram) IV (intravenously), Zofran (anti-nausea medication) 4 mg IV and Toradol (muscle relaxer/pain medication) 30 mg IV. Record review revealed RN #1 administered Dilaudid and Zofran at 1133 and the Toradol at 1201. Further record review revealed Patient #8 was discharged at 1542. Record review revealed no documentation of reassessment of Patient #8's pain level and no documentation that Patient #8's blood pressure was reassessed (4 hours, 33 minutes after initial assessment).

Interview on 05/08/2013 at 1030 with administrative nursing staff revealed RN #1 did not follow the hospital's policy for reassessment of pain after the administration of pain medication. Interview further revealed, "the nurse should have repeated taking this patient's blood pressure prior to discharge". Interview confirmed RN #1 failed to follow the hospital's policy for pain reassessment and reassessment of a patient's blood pressure prior to discharge.

RN #1 was not available for interview.

2. Closed ED (emergency department) record review of Patient #7 revealed a 29 year-old female who presented to the ED on 05/04/2013 at 0620 with chief complaint of abdominal pain. Record review revealed the patient was triaged at 0632 by RN #2. Record review revealed documentation by RN #2 that Patient #7's pain level was 8 of 10, on a scale of 1 to 10, with 10 being the most severe pain. Record review revealed a physician's order at 0700 for Toradol (muscle relaxer/pain medication) 30 mg (milligrams) IV (intravenously) and Zofran (anti-nausea medication) 4 mg IV. Record review revealed RN #2 administered Toradol and Zofran at 0723. Further record review revealed Patient #7 was discharged at 0903. Record review revealed no documentation of reassessment of Patient #7's pain level.

Interview on 05/08/2013 at 1030 with administrative nursing staff revealed RN #2 did not follow the hospital's policy for reassessment of pain within 60 minutes after the administration of pain medication. Interview confirmed RN #2 failed to follow the hospital's policy for pain reassessment.

RN #2 was not available for interview.

3. Closed ED (emergency department) record review of Patient #5 revealed a 31 year-old female who presented to the ED on 05/06/2013 at 2144 with chief complaint of migraine headache. Record review revealed the patient was triaged at 2218 with pain level reported as 8 of 10, on a scale of 1 to 10, with 10 being the most severe pain. Record review revealed a physician's order (not timed) for Benadryl (anti-histamine) 10 mg (milligrams) by mouth, Reglan (anti-nausea medication) 10 mg by mouth, Toradol (muscle relaxer/pain medication) 60 mg IM (intramuscularly) and Imitrex (anti-migraine medication) 6 mg subcutaneously. Record review revealed the ordered medications were administered by RN #3 at 2243. Further review revealed the physician ordered and RN #3 administered Zofran (anti-nausea medication) 8 mg by mouth at 2252. Record review revealed RN #3 reassessed Patient #5's pain level at 0012 (1 hour, 19 minutes after administration).

Interview on 05/08/2013 at 1030 with administrative nursing staff revealed RN #3 did not follow the hospital's policy for reassessment of pain within 60 minutes after the administration of pain medication. Interview confirmed RN #3 failed to follow the hospital's policy for pain reassessment.

RN #3 was not available for interview.

NC00088257