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Based on review of medical records, facility policies and procedures, and staff interviews it was determined that the facility failed to provide a nursing assessment to one Patient (P) (P #2) of five sampled patients when P #2 received Benadryl (medication used for allergy and itching) and Morphine (a controlled medicine used for severe pain) (IV) intravenously (through a small catheter into a vein) at 7:48 p.m. on 5/22/23 and was discharged at 8:15 p.m. A nursing reassessment was not performed on P#2 prior to discharge.

Review of P #2's medical record revealed that she received the following medications on 5/22/23:
4:08 p.m., Peripheral IV line started by RN GG.
4:11 p.m. RN started IV fluids
4:11 p.m. RN GG administered Morphine 4mg IV.
4:11 p.m. RN GG administered Zofran (medication used for nausea and vomiting) 4mg IV.
5:28 p.m. P #2 received Protonix (medication that treated acid reflux in the stomach) 40mg.
4:32 p.m. P #2 received Mylanta (a medication used to treat too much acid in the stomach) Oral suspension.
5:28 p.m. RN GG did a pain assessment for P #2 and the pain was described as severe.
5:29 p.m. RN GG administered P #2 Morphine 4mg IV
5:47 p.m. P #2's vital signs included: Blood Pressure: 114/66, Heart Rate:85, Oxygen Saturation: 98% at room air.
5:56 p.m. P #2 received Decadron 10 mg IV (a steroid used for congestion of the lungs and cough).
5:57 p.m. P #2 received Benadryl 12.5 mg IV
7:22 p.m. P #2 received Pepcid 20mg IV (medication to treat excess acid in the stomach)
7:48 p.m. P #2 received Benadryl 12.5mg IV and Morphine 4 mg IV. RN HH Administered both medications.
7:48 p.m. IV fluid stopped.
7:52 p.m. RN HH removed the IV line from P #2's arm.
8:14 p.m. RN HH progress notes stated P #2's departure condition was "Good" and P #2's mobility at departure was ambulatory. The notes stated P #2 ambulated easily and independently to the registration area. There was no further relevant nursing documentation.
8:15 p.m. P #2 was discharged.

A review of the facility policy titled "Medication Administration for Ambulatory Care", effective 1/19/23 revealed the purpose of the policy was to ensure that medications were administered safely. The policy delineated under its procedures that only licensed medical providers and authorized clinical staff, acting within their legally defined scope of practice and Clinic policies may administer medications to patients. Further review of the "Procedures" section of the policy on page 5 number 16 revealed that it was the facility's policy to observe patients receiving high alert medications (high-alert medications were defined as drugs that carried high risk of causing significant patient harm when they were used in error) or allergy injections for at least 30 minutes.

A review of the facility policy titled "Pain Management", effective 11/30/22 revealed it was the policy of the facility to ensure optimal patient comfort through a proactive pain control plan that was mutually established with the patient, family members, and members of the healthcare team. The policy stated all patients had the right to appropriate assessment and management of pain. This policy established standards for safe and effective pain management for patients receiving care within the facility. The rationale behind the policy stated that effective pain assessment and management could remove the adverse psychological and physiological effects of unrelieved pain. The policy delineated that Optimal management of the patient experiencing pain enhanced healing and promoted both physical and psychological wellness. The policy statement indicated that the standard of the facility was to provide every patient with effective pain management as a part of their plan of care.

A review of Section E under "Policy Statement "revealed that patients were to receive interventions (pharmacological and/or non-pharmacological to reduce or eliminate pain associated with their diagnoses, procedure or treatment and were to be re-assessed for the effectiveness of the intervention(s) within one-hour of intervention. This reassessment was to be documented.

A review of Section H under "Policy Statement" revealed that following pharmacological interventions, the patient's level of sedation was to be assessed using the Pasero Opioid Sedation Scale (POSS) (POSS: a valid, reliable tool used to assess sedation after administration of opioid medications for pain) along with pain reassessment; this assessment was to be done within 1 hour of any intervention. The policy explained that The POSS was designed to identify unintended opioid-induced respiratory depression.

A review of Section C "Pain Reassessment" of the policy revealed that patients receiving interventions in pain management had to be reassessed within one-hour of interventions. The policy stated for both pharmacological and non-pharmacological pain interventions, effectiveness of the intervention was evaluated through reassessment.
The policy reiterated that following pharmacological intervention, patient level of sedation was to be assessed using the Passero Opioid Sedation Scale (POSS), as part of the pain reassessment.





During a phone interview with Registered Nurse (RN) GG on 12/5/23 at 11:45 a.m., RN GG said the nurses monitored all patients after they received medications. RN GG said he did not remember P #2 therefore he could not tell why the patient was not assessed after she received medicines. RN GG explained that it was protocol for the nurses to assess patients after they gave them pain medicines.

During an interview with Unit Director (Unit Director) of Emergency Services and Clinical Decision Unit (II) on 12/5/23 at 1:30 p.m. in his office, Unit Director II reviewed P #2's medical record and concluded in a statement that P #2 should have stayed at least 30 minutes for the nurse to watch him. Unit Director II said the facility followed their established Medication Administration's policies and procedures and also the Lippincott Procedure Manual. Unit Director II said they encouraged the nursing team to discharge patients in wheelchairs, but the concern was that the nurse should have kept P #1 after he received the Morphine and the Benadryl. Unit Director II said that was a very isolated case because the nurses were well aware of policies of patient assessment after giving certain medications that could cause patients to experience changes in mental state and in blood pressure. Director II explained that staff were instructed to discharge patients in a wheelchair, especially after they received narcotics. Unit Director II confirmed RN HH did not work at the facility anymore.


During an interview with Charge Nurse KK on 12/5/23 at 2:15 p.m. in Director II's office, Charge Nurse KK said she had been a Charge Nurse for about five years total. Charge Nurse KK admitted there should have been a pain assessment completed for P #2 before RN HH discharged him. Charge Nurse KK explained that nurses should document a brief discharge summary about the effectiveness of administered medication. Charge Nurse KK said went on to explain that vital signs were a part of the post medication administration assessment before discharge that should be completed within an hour of discharge. Charge Nurse KK said that the last vital signs recorded in P #2's medical record was too old and RN HH should have taken P #1's vitals again at the time of discharge.

A request was made to interview RN HH. Facility administrator confirmed RN HH was no longer working at the facility and was not available to be interviewed.