HospitalInspections.org

Based on policy review, job description review, document review and staff and family interview, the Acute Hospital staff failed to provide patient reassessments and management of pain in 4 of 19 closed patient medical records reviewed (Patients # 1, 2, 3, and 4). The Acute Hospital reported an average daily census in the Emergency Department of 52.08 patients.

Failure to provide appropriate reassessment could potentially result in delays in provision of needed interventions and adversely affect the health of patients who require emergency care.

Findings included:

1. Review of hospital policy titled Emergency Department Policy & Procedures #P-35 (Revision date 11/15/09) revealed in part:
... "All patients presenting to the Emergency Department will receive care based on a documented assessment of their needs, interventions, and outcomes ..."
..."Reassessment is at the discretion of the nurse and is to be completed based on condition of the patient ..."
..."Pain Assessment on a 1-10 scale ..."
..."Patient reassessments are performed to determine if care decisions and interventions have been appropriate and effective. Reassessment is ongoing and may be triggered by key decision points and at intervals based on the needs of each patient ..."

2. Review of hospital policy titled Emergency Department Policy & Procedure #P-64 (Revision date 4/18/08) revealed in part:
..."All patients should receive treatment for pain relief as warranted and monitored for effectiveness ..."
..."ED staff will assess all patients upon admission to the area using the 0-10 Pain Rating Scale. Assessment will be documented in the medical record; reassessment will be dependent upon the patient's presenting problem, acuity, past medical history and initial vital signs ..."

3. Review of hospital policy titled Assessment of Patient Policy & Procedures # 3.4 (Revision date 11/10/08) revealed in part:
... "ED: Reassessment of ED patients will be based upon the patient's presenting problem and acuity ..."
... "All patients that have abnormal vital signs upon admission to the ED will have at least one set of repeat vital signs prior to discharge ..."
..."Emergency Department patients that are acuity level IV, V, or Critical Care will be reassessed including vital signs at least every 30 minutes or as patient condition warrants ..."

4. Review of hospital policy titled Administrative Policy & Procedure #155 (Revision date 6/07) revealed in part:
..."Pain assessment: A reassessment will be completed after a pain control intervention is employed to evaluate its effectiveness ..."
... "Pain Management Intervention: If pain is rated greater that 4 (on a 0-10 scale) or more than mild or is unacceptable to the patient, there will be an intervention to reduce the pain. If pain is not improving, additional measures should be taken unless reasons for waiting longer are documented ...

5. Review of hospital job descriptions titled Registered Nurse (Triage) revealed in part:
..."Major Duties and Responsibilities - Maintains the standards of nursing care and implements policies and procedures of the hospital and Nursing Department ..."

6. Review of the closed medical record for patient #1, admitted to the ED on 12/29/09 at 3:42 PM and discharged on 12/29/09 at 5:33 PM, revealed staff completed a pain assessment at 3:55 PM. Staff documented a pain scale of 10. The emergency treatment record lacked documentation of treatment for pain relief, interventions to reduce pain, reassessment of pain and repeat vital signs prior to discharge. Patient #1 presented to the ER with complaints of hand injury. Discharge diagnosis identified a comminuted, palmar-angulated fracture of the fifth metacarpal. During an interview on 4/7/10 at 3:40 PM, the EMS Director confirmed findings. The EMS Director stated, "A reassessment by the nurse or some explanation of why the pain level was a 10 should have been completed."

7. Review of the closed medical record for patient #2, admitted to the ED on 12/04/09 at 3:53 PM and discharged on 12/04/09 at 4:57 PM, revealed staff completed a pain assessment at 4:02 PM. Staff documented a pain scale of 7. The emergency treatment record lacked documentation of treatment for pain relief, interventions to reduce pain, reassessment of pain and repeat vital signs prior to discharge. Patient #2 presented to the ER with complaints of pain and right thumb injury. Discharge diagnosis identified a fractured distal phalanx of the right thumb. During an interview on 4/7/10 at 3:40 PM, the EMS Director confirmed findings. The EMS Director stated, "Per policy there should have been another set of vitals and reassessment of pain."

8. Review of the closed medical record for patient #3, admitted to the ED on 3/11/10 at 11:44 AM and discharged on 3/11/10 at 3:06 PM, revealed staff completed a pain assessment at 11:48 AM. Staff documented a pain scale of 10. The emergency record lacked documentation of treatment for pain relief, interventions to reduce pain, reassessment of pain. Patient #3 presented to the ER with complaints of finger injury. Discharge diagnosis identified an open tuft fracture to the left ring finger, 2.2 centimeter (cm) in length, simple repair. During an interview on 4/7/10 at 3:40 PM, the EMS Director confirmed findings. The EMS Director stated, "Based on the pain level alone there should be a reassessment of pain or something in the nurses' notes. Additional documentation should have been completed and there should have been interventions which could have included ice, elevation, or analgesics."

9. Review of the closed medical record for patient #4, admitted to the ED on 2/22/10 at 2:31 PM and discharged on 2/22/10 at 5:50 PM, revealed staff completed a pain assessment at 2:40 PM. Staff documented a pain scale of 8. The medical record lacked documentation of reassessment of pain until 5:50 PM (three and a half hours after the patient presented to the ER). Patient #4 presented to the ER with complaints of hand injury. Discharge diagnosis identified right hand fractures of the midshaft fourth and fifth metacarpals with palmar angulation of the distal fragment. The patient required two orthopedic surgeries to repair the fractures subsequent to the ER stay. During an interview on 4/7/10 at 3:40 PM, the EMS Director confirmed findings. The EMS Director stated, "Based on the 8 of 10 pain level would warrant a reassessment from the nurse or something in the nurses' notes. This shows me some additions and changes I need to make, implement and educate the nurses on."

10. During an interview on 4/5/10 at 11:45 AM, Patient #4's family member stated, "[Patient #4] slipped on the ice and broke his/her fingers. He/she was in a lot of pain. I asked for something for pain and they gave [Patient #4] an ice pack. We sat for about an hour, I asked again for something for pain, and the nurse said he'd /she'd check with doctor. They brought a pill in, that was three hours later. My [family member] was there for 3-4 hours and he/she got nothing from pain. When you're in pain like that and they know your fingers are broken, I think they should be able to give pain medicine right away. As far as I'm concerned they ignored his/her pain, and that's not right."

11. During an interview on 4/5/10 at 11:55 AM, Staff A, Registered Nurse (RN) on the Emergency Department (ED) stated, "The pain level is assessed at triage. If pain is unbearable, we would get the physician and report to him/her immediately. The physician's would come into see the patient and then give pain level and may be medicated. I am always reassessing pain level during the patient's stay."

12. During an interview on 4/5/10 at 12:05 AM, Staff B, RN/ED stated, "Pain is assessed every 20-30 minutes and then before discharge."

13. During an interview on 4/5/10 at 12:20 PM, Staff C, RN/ED stated, "It is possible that I may have to offer alternatives for terrible pain including ice, pillow or get an x-ray. This would be documented in the patient's record and the patient's response to the alternatives."

14. During an interview on 4/6/10 at 4:20 PM, Staff D, RN/ED stated, "The 0-10 pain scale would be used to assess pain. Emergent would be 8-9 on the scale. A pain level of 7 would not be emergent but would need to be treated and attended."