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Based on document review, policy review, record review and interview, the hospital failed to ensure an effective process was implemented to investigate and resolve complaints/grievances and provide the patient/family with written notice of the decisions and/or findings of the investigation of the complaints/grievances for 2 of 2 sample patients (Patient #1 and #3) seen in the Emergency Department (ED) who had complaints/grievances. The hospital failed to ensure seclusion was utilized appropriately and in accordance with hospital policy for 1 of 1 sample pediatric patients (Patient #4) seen in the ED for psychiatric complications. The hospital failed to ensure ongoing pain assessments were conducted and pain medications administered for 2 of 3 (Patient #1 and #2) sampled adults seen in the ED. The hospital failed to perform neurological assessment per physician's order for 1 of 3 (Patient #3) sampled adult patients seen in the ED.

The findings included:

1. Patient #1 presented to the hospital's emergency department (ED) on 4/1/21 with chief complaints of altered mental status, lethargic and not eating. Patient #1 had an active diagnosis of Stage 3-4 Pancreatic Cancer.
See A119 and A123 for additional information regarding the admission of Patient #1.

2. Review of the hospital's grievance investigation for Patient #1 revealed a complete investigation was not conducted. Multiple emails were sent to the hospital from the complainant with no resolutions provided to the family.
See A119 for additional information regarding the lack of a thorough investigation and resolution for Patient #1.

3. Review of the hospital's grievance investigation for Patient #1 revealed no written notice of the hospital's process and results of the grievance process was provided to Patient #1 or the family.
See A123 for additional information regarding the lack of a written resolution for Patient #1.

4. Review of the ED initial Nursing assessment revealed it was completed 4/1/2021 with no documentation of complaints of pain at the time of the assessment. Record review revealed Patient #1 no pain assessments or medication for pain was administered for 19 hours after presentation to the ED.
See A395 for additional information regarding the lack of pain assessments and pain medication administered for Patient #1.

5. Patient #2 presented to the hospital's ED on 3/19/2021 with diagnoses which included Altered Mental Status, Hypoglycemia and Fatigue. An initial pain assessment was completed on 3/19/2021 after Patient #2 arrived at the hospital's ED; a second pain assessment was completed 22 hours later with actual pain documented; a third pain assessment was completed 29 hours after the patient presented to the hospital's ED. The patient received no pain medication for 29 hours after presentation to the hospital's ED.
See A395 for information regarding lack of pain medication administered for Patient #2's pain.

6. Patient #3 was admitted to the hospital for inpatient care on 3/6/2021 with diagnoses that included Acute Stroke, Bilateral Lung Infiltrates and Hypercalcemia. A complaint/grievance was placed on 3/15/2021 related to care received during the hospitalization.
See A119 for information regarding the lack of a thorough investigation and resolution for Patient #3.

7. Review of the care plan for Patient #3 revealed there was no neurological assessment performed as ordered by the physician after admission to the hospital with Acute Stroke.
See A396 for information regarding the lack of neurological assessment performed for Patient #3.

8. Patient #4 presented to the hospital's ED on 3/28/21 with a chief complaint of intentional overdose in an attempt to kill herself.
See A162 and A168 for additional information regarding the admission of Patient #4.

9. Patient #4's ED documentation revealed the patient was placed in seclusion for the management of violent or self-destructive behavior with no documentation of behaviors at the time of seclusion.
See A162 for additional information regarding the inappropriate management and use of seclusion for Patient #4.

10. Patient #4's ED documentation revealed the patient was placed in restraints without a valid physician's order.
See A168 for additional information regarding the use of restraints and seclusion without a physician's order for Patient #4.

Based on policy review, medical record review and interview, the hospital failed to be responsible for ensuring an effective process to review, investigate and resolve complaints/grievances for 2 of 2 (Patient #1 and # 3) sampled patients with seen in the hospital's Emergency Department (ED) with complaint/grievances.

The findings included:

1. Review of the Complaint Grievance Policy revealed, "...Purpose and Responsibilities...Provide a process to review, investigate, and resolve a patient's/patient representative's complaint/grievance within a reasonable time frame. Provide a process to determine the effectiveness of the complaint and/or grievance process through Quality Improvement monitoring to help identify, investigate and resolve any deeper, systemic problems indicated by the grievance analysis...The Governing Board has delegated the Complaint and Grievance process to the Hospital Quality/Risk Department...The Quality Improvement Committee has designated specific responsibilities to the following roles: CEO [Chief Executive Officer]: writing and sending response letters to patients/family. Quality Director: Auditing, aggregating and analyzing data to present to the Quality Improvement Committee and Medical Staff committees for review and recommendation...Grievances shall be tracked for the purpose of trending, improving the processes, and ensuring customer satisfaction and service recovery. (See Complaint/Grievance Log)..."
Further review of the Complaint Grievance Policy revealed when a complaint or grievance is initiated, staff receiving the complaint is to initiate a report using the online Event Reporting System (ERS).
The facility was unable to provide any documentation regarding using the ERS for this investigation.
The policy further revealed, "...The hospital CEO...shall receive the report form within a reasonable time frame (the goal is to have the CEO in receipt of the completed sections within 72 hours) to proceed with a written response to the patient/representative..."

2. Medical record review for Patient #1 revealed the patient presented to the hospital's ED on 4/1/2021 at 2:08 PM with chief complaints of altered mental status, lethargic, not eating. Patient #1 had an active diagnosis of Stage 3-4 Pancreatic Cancer.

Review of the Complaint/Grievance Log dated February, 2021 through April 29, 2021 revealed no documentation of Patient #1's family's complaints/grievances that began on 4/2/2021.

Review of the hospital's investigation revealed the first notification from Patient #1's family member to the hospital was via email dated 4/2/2021 at 9:28 AM. (Patient #1 was still in the ED at the time this email was sent to hospital customer service.) The email was forwarded on 4/2/2021 to the CEO, Director of ED, ED Nurse Manager, CNO, and Educator.
The complaint/grievance email revealed Patient #1's family member was very concerned and upset regarding the following:
- Patient #1's pain had not been addressed. The email documented, "...I [Patient #1's family member] have been asking for pain meds for OVER 12 HOURS, and [Patient #1] has yet to get them..."
- Nursing staff was rude and uncaring. The email documented, "...when the family is concerned for their loved one. But to have a nurse say she pretty much is tired of repeating the same information..."
-Nursing staff was not attentive to personal care needed. The email documented, "...It should be almost impossible to have a patient defecate on themselves and you not know it, BUT, that happened. You could smell it in the room, yet [Named Registered Nurse (RN) #2] didn't notice..."

The Director of the ED responded to the email from Patient #1's family member on 4/2/2021 at 11:29 AM. The response revealed, "...I was forwarded your email regarding concerns about [Patient #1's] care last night...I apologize for any lack of care or concern [Patient #1] and your family may have experienced in our emergency department. Please feel free to reach out to me at your convenience..."

Patient #1's family member responded to the Director of ED via email on 4/2/2021 at 12:57 PM [Central Time]. The email documented, "Thanks for responding...I appreciate the apology, however, this email complaint was not to trigger an apology, it was to trigger better care...[Patient #1] laid in pain for over 12 hours, from the time [Patient #1] was admitted until this morning. We asked for [Patient #1] to receive pain medications multiple times, from multiple people, and it still did not happen...This is a hard and difficult time for the family, and all the doctors have been saying was "there is nothing left to do, except keep [Patient #1] comfortable,and this hospital has failed to do even that...a failure is an attempt at something and not succeeding, there wasn't even an attempt to keep [Patient #1] out of pain because the entire family had to literally beg for pain medications. I am glad she finally was moved from ER [Emergency Room]..."

The hospital was unable to provide any documentation that an investigation had been initiated related to the complaints received on 4/2/2021. There was no documentation provided that a formal investigation was opened utilizing the electronic Event Reporting System. There was no documentation provided by the hospital of actions taken regarding the complaints of pain management, nurse communication (rudeness, uncaring) or physical care regarding bowel movements.

Review of an email dated 4/6/2021 from the Chief Executive Officer (CEO) sent to the Chief Nursing Officer (CNO) and the Chief Quality Officer documented, "...This needs serious investigation and response to the family."

Review of the hospital's investigation revealed multiple emails dated 4/2/2021 through 4/15/2021 sent back and forth between the complainant and hospital leadership. Review of the emails revealed no documentation of any actions taken by the hospital regarding the Complainant's concerns.

In an interview on 4/30/2021 at 11:25 AM in the Quality Assurance (QA) Department, the Director of Human Resources confirmed a telephone interview with RN #2 while in the presence of the Director of the ED. The Director of Human Resources stated RN #2 was able to return to work after it was determined RN #2 did not intentionally neglect Patient #1.

In an interview on 4/30/2021 at 12:15 PM with the Risk Manager, the Risk Manager confirmed she did not receive any information regarding this grievance until 4/6/21. The Risk Manager further stated that complaints/grievances are handled by the specific unit directors and managers and any education would be done to the specific nurse when needed.

In an interview on 4/30/2021 at 12:30 PM in the QA Department the Quality Coordinator confirmed the hospital did not have a policy for customer responsiveness and communication.

3. Medical record review revealed Patient #3 was admitted to the hospital on 3/6/2021 - 3/9/2021 with diagnoses that included Acute Stroke, Bilateral lung infiltrates and Hypercalcemia.

Record review revealed a complaint was filed on behalf of the patient on 3/15/2021. The "Statement of Grievance" complaint included the following complainants:
-The staff were rude and brash. The nurses were not kind or gentle.
-The patient (Patient #3) was placed in a room with another patient. The other patient yelled constantly and wore a diaper and the smell was horrible. The other patient's family members were fighting. Patient #3 did not get any rest.
-The privacy curtain did not hang correctly.
-The patient requested to move to another room; this was not addressed.
-The complainant requested a call back after Patient #3 was called to inform of the hospital's follow up.
Review of the complaint revealed the Risk Manager (RM) spoke to Patient #3 and the patient thanked the RM for hearing the complaint. There was no documentation of a complete investigation and resolution to the complaint.

In an interview on 4/30/2021 at 10:50 AM in the QA department, the RM was asked about the complaint. The RM stated that she was responsible for the investigation and resolution of the complaint.
The RM stated that she called and spoke with the patient on 3/15/2021. The patient added that they couldn't eat because the room smelled like BM (Bowel Movement).
The patient stated that she talked to the Interim Manager while she was an inpatient. The RM stated the interim manager had since resigned and there was no information on what was discussed.
The RM was asked about the investigation and resolution for this complaint. The RM stated, "It was me listening to her complaints. It was an informal complaint. She didn't ask for anything in writing."

There was no documentation the facility reviewed/investigated the complaint/grievance, or resolved the complaint/grievance and notified the complainant of the resolution.

Based on document review, medical record review, and interview, the hospital failed to provide the patient/family with written notification of the facility's investigation into the grievance that included the steps and results of the grievance process for each of the concerns voiced by the complainant and the date of the completion for 1 of 2 (Patient #1) sampled patients with grievances reviewed.

The findings included:

1. Review of the Complaint Grievance Policy revealed, "...All verbal or written complaints regarding discrimination, abuse, neglect, patient harm, or hospital compliance with CoPs [Conditions of Participation] are grievances...A written complaint is always considered a grievance (including e-mail or fax), whether from an inpatient, outpatient, released or discharged patient or his/her representative...Purpose and Responsibilities...Provide a process to review, investigate, and resolve a patient's/patient representative's complaint/grievance within a reasonable time frame. Provide a process to determine the effectiveness of the complaint and/or grievance process through Quality Improvement monitoring to help identify, investigate and resolve any deeper, systemic problems indicated by the grievance analysis...The Governing Board has delegated the Complaint and Grievance process to the Hospital Quality/Risk Department...The Quality Improvement Committee has designated specific responsibilities to the following roles...CEO [Chief Executive Officer]: writing and sending response letters to patients/family. Quality Director: Auditing, aggregating and analyzing data to present to the Quality Improvement Committee and Medical Staff committees for review and recommendation...The Hospital Quality/Risk Department ensures the patient is provided written notice of its receipt, investigation and outcomes regarding a complaint/grievance...The written notice shall contain the following: Name of the Hospital contact person. Steps taken on behalf of the patient to investigate the grievance. Results of the grievance process. Date of completion...Grievances shall be tracked for the purpose of trending, improving the processes, and ensuring customer satisfaction and service recovery. (See Complaint/Grievance Log)..."

Further review of the Complaint Grievance Policy revealed when a complaint or grievance is initiated, staff receiving the complaint is to initiate a report using the online Event Reporting System (ERS).
The facility was unable to provide any documentation regarding the investigation using the ERS.
The policy revealed, "...The hospital CEO...shall receive the report form within a reasonable time frame (the goal is to have the CEO in receipt of the completed sections within 72 hours) to proceed with a written response to the patient/representative...The CEO is responsible for completing and sending a letter to the complainant in response to a complaint/grievance. The letter shall include the name of the Hospital contact person, steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion..."

2. Medical record review for Patient #1 revealed the patient presented to the hospital's dedicated emergency department on 4/1/2021 at 2:08 PM with chief complaints of altered mental status, lethargic, not eating. Patient #1 had an active diagnosis of Stage 3-4 Pancreatic Cancer.

Review of the Complaint/Grievance Log dated February, 2021 through April 29, 2021 revealed no documentation of Patient #1's family's complaints/grievances beginning on 4/2/2021.

Review of the hospital's investigation revealed the first notification from Patient #1's family member to the hospital was via email dated 4/2/2021 at 9:28 AM. (Patient #1 was still in the ED at the time this email was sent to hospital customer service.) The email was forwarded on 4/2/2021 to the CEO, Director of ED, ED Nurse Manager, CNO, and Educator. The email revealed Patient #1's family member was very concerned and upset that Patient #1's pain had not been addressed. The email revealed, "...I have been asking for pain meds for OVER 12 HOURS, and [Patient #1] has yet to get them. Absolutely unacceptable...they might as well just close the door and let her pass away painfully, and uncomfortably in the night, because that's how [Patient #1] has been since being admitted...BUT, [Nursing staff] should also understand that a family in this predicament is going to be asking questions often. Wanting to know what's going on. It's a natural response, especially when the family is concerned for their loved one. But to have a nurse say she pretty much is tired of repeating the same information, sent me over the edge. I don't care if I ask the same question 1000 times, as a nurse you should be able to and willing to answer families questions, especially when the patient is in no condition to ask questions themselves...It should be almost impossible to have a patient defecate on themselves and you not know it, BUT, that happened. You could smell it in the room, yet [Named RN #2] didn't notice..."
The Director of the ED responded to this email on 4/2/2021 at 11:29 AM. The response revealed, "...I was forwarded your email regarding concerns about [Patient #1's] care last night...I apologize for any lack of care or concern [Patient #1] and your family may have experienced in our emergency department. Please feel free to reach out to me at your convenience..."

Patient #1's adult child (complainant) responded to the Director of ED via email on 4/2/2021 at 12:57 PM [Central Time]. The email revealed, "Thanks for responding...I appreciate the apology, however, this email complaint was not to trigger an apology, it was to trigger better care...[Patient #1] laid in pain for over 12 hours, from the time [Patient #1] was admitted until this morning. We asked for [Patient #1] to receive pain medications multiple times, from multiple people, and it still did not happen...This is a hard and difficult time for the family, and all the doctors have been saying was "there is nothing left to do, except keep [Patient #1] comfortable:, and this hospital has failed to do even that...a failure is an attempt at something and not succeeding, there wasn't even an attempt to keep [Patient #1] out of pain because the entire family had to literally beg for pain medications. I am glad she finally was moved from ER..."

The Director of the ED responded to the email on 4/2/2021 at 1:32 PM The response revealed, "...I know it does not help the situation with [Patient #1], but please know that I will personally follow up with [Named RN #2] to discuss the failure to perform the duties expected of a nurse in our facility...Please accept my heartfelt sympathy for the situation you and your family are currently experiencing..."

The hospital was unable to provide any documentation that an investigation had been initiated related to the complaints received via email on 4/2/2021. There was no documentation provided that a formal investigation was opened utilizing the electronic Event Reporting System. There was no documentation provided by the hospital of actions taken regarding the complaints of pain management, nurse communication (rudeness, uncaring) or physical care regarding bowel movements.

Review of the hospital's investigation revealed multiple emails dated 4/2/2021 through 4/15/2021 sent back and forth between the complainant and hospital leadership. Review of the emails revealed no documentation of any actions taken by the hospital regarding the Complainant's concerns.

In an interview with the Risk Manager on 4/30/2021 at 12:15 PM, the Risk Manager confirmed she had no knowledge of any letter regarding resolution of the grievances being mailed to the complainant.

During a telephone interview on 5/5/2021 at 12:22 PM, the complainant confirmed no letter from this hospital regarding the complaint/grievance was received.

Based on policy review, record review and interview, the hospital failed to ensure seclusion was only used for the management of violent or self-destructive behavior and in accordance with the hospital's policy for 1 of 1 (Patient #4) sampled pediatric patients seen in the Emergency Department (ED).

The findings included:

1. Review of the "Restraint and Seclusion" policy revealed, "...This facility ensures that restraint and seclusion interventions are safely and appropriately used. Because of the associated risks and consequences of use, this facility is continually exploring ways to decrease restraint use through effective preventative strategies or the use of alternatives...Seclusion: Involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior ...ORDERS FOR RESTRAINT... The physician or LIP [Licensed Independent Practitioner] responsible for the care of the patient is authorized to order a restraint and seclusion must have a working knowledge of hospital policy regarding restraint and seclusion... In an emergency application situation, a RN [Registered Nurse] who has documented Restraint and Seclusion competency may initiate the application of the restraint or seclusion prior to obtaining an order from a LIP... In this event the order must be obtained either during the emergency application of the restraint or seclusion or immediately within a few minutes) after the restraint or seclusion has been applied..."

2. Medical record review revealed Patient #4 (a 17 year old) was brought to the Emergency Room via ambulance on 3/28/2021 at 11:02 PM with the chief complaint of intentional overdose in an attempt to commit suicide.

Review of the "RN Assessment for Restraint/Seclusion" dated 3/28/2021 revealed the patient was in physical restraints from 11:15 PM - 11:30 PM. At 11:19 PM the patient was received Benadryl 50 milligrams (mg), Haldol 5 mg and Ativan 2 mg intravenously.

Review of the "RN Assessment for Restraint/Seclusion" revealed the patient was placed in "Seclusion" from 3/28/2021 at 11:30 PM - 3/29/2021 at 4:30 AM.
The assessment revealed the "Indication for Seclusion" was "Patient demonstrates behavior that poses an imminent danger to self or others."
Review of the 1:1 observation form revealed every 15 minute documentation of the patient's behaviors. The 3/28/2021 documentation from 11:30 PM - 12:00 midnight revealed Patient #4 was "lying in bed." The every 15 minute documentation on 3/29/2021 from 12:15 AM - 4:30 AM revealed Patient #4 had the behavior of "sleeping."
There was no documentation of Patient #4 having violent or self-destructive behavior to justify the use of Seclusion.

In a telephone interview on 4/30/2021 at 1:30 PM revealed RN #1 stated she did not recall the events for Patient #4.

In a telephone interview on 5/5/2021 at 2:37 PM the Chief Quality Officer verified there were no physician's orders for the use of restraints or seclusion.

Based on policy review, record review and interview, the hospital failed to ensure restraints and seclusion were only used under the order of a physician or licensed practitioner for 1 of 1 (Patient #4) sampled pediatric patients reviewed for restraint usage.

The findings included:

1. Review of the "Restraint and Seclusion" policy revealed, "...Definitions... Restraint: is any physical or mechanical device, material, medication, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, or head freely ...The physician or LIP {LIP} [LIP-Licensed Independent Practitioner] responsible for the care of the patient is authorized to order a restraint and seclusion must have a working knowledge of hospital policy regarding restraint and seclusion... In an emergency application situation, a RN [Registered Nurse] who has documented Restraint and Seclusion competency may initiate the application of the restraint or seclusion prior to obtaining an order from a LIP [Physician or Licensed Independent Practitioner] ... In this event the order must be obtained either during the emergency application of the restraint or seclusion or immediately within a few minutes) after the restraint or seclusion has been applied..."

Review of the "Code Mr. Atlas Policy" revealed, "...The hospital 'Code Mr. Atlas' alert is utilized in emergency situations when a patient, visitor or employee becomes disruptive and demonstrates the potential to: Inflict physical harm on themselves or others ... Damage the physical property of [Name of the hospital] or other's property ..."

2. Medical record review revealed Patient #4 (a 17 year old) was brought to the Emergency Department (ED) via ambulance on 3/28/2021 at 11:02 PM with the chief complaint of intentional overdose in an attempt to commit suicide.

Record review revealed on 3/28/2021 at 11:07 PM, 5 minutes after the patient arrived in the ED, a code ATLAS was called. Four (4) Security Officers arrived and assisted the ED nursing staff place Patient #4 in 4 point restraints (restraints to tie down both the patient's arms and legs).

Review of the "RN Assessment for Restraint/Seclusion" dated 3/28/2021 revealed the patient was in physical restraints from 11:15 PM - 11:30 PM. The assessment revealed the "Patient demonstrates behavior that poses an imminent danger to self or others..."
There was no documentation of a physician's or LIP's order for the use of the 4 point physical restraints used on Patient #4.

Interviews on 5/3/2021 with all 4 Security Officers revealed they immediately responded to the Mr. Atlas Code to assist the ED nursing staff in physically restraining Patient #4.

In a telephone interview on 5/5/2021 at 2:37 PM the Chief Quality Officer verified there were no physician's orders for the use of restraints or seclusion for Patient #4.

Based on document review, policy review, record review and interview, the hospital failed to assess and treat pain in the Emergency Department (ED) for 2 of 3 (Patient #1 and #2) sampled adult patients seen in the ED. The hospital failed to have an organized nursing service which provided ongoing assessments of patients' needs and developed a plan of care in order to ensure they provided the services to meet those needs for 1 of 3 (Patient #3) sampled adult patients.

The findings included:

1. Patient #1 presented to the hospital's emergency department (ED) on 4/1/21 with chief complaints of altered mental status, lethargic and not eating. Patient #1 had an active diagnosis of Stage 3-4 Pancreatic Cancer.
See A395 for additional information regarding the admission of Patient #1.

2. Review of the ED nursing pain assessments revealed no pain assessments were documented on Patient #1 for approximately 19 hours. There was no documentation of family or patient complaints of pain and no documentation a physician was notified.
See A395 for additional information regarding the lack of assessments and lack of pain management for Patient #1.

3. Patient #2 presented to the hospital's ED on 3/19/21 with chief complaints of altered mental status, hypoglycemia and fatigue.
See A395 for additional information regarding the admission of Patient #2.

4. Review of the ED nursing pain assessments revealed no pain medication was administered after Patient #2 complained of pain during 2 pain assessments performed approximately 13 hours apart.
See A395 for additional information regarding the lack of assessments and lack of pain management for Patient #2.

5. Patient #3 was admitted to the hospital on 3/6/21 with diagnoses that included Acute Stroke, Bilateral lung infiltrates and Hypercalcemia.
See A396 for additional information regarding the admission of Patient #3.

6. Review of the plan of care for Patient #3 revealed no documentation of neurological checks every 4 hours for 24 hours.
See A396 for additional information regarding Patient #3 not receiving neurological checks as ordered by the physician.

Based on document review, medical record reveiw, and interview, the hospital failed to ensure Emergency Department (ED) nursing staff provided ongoing pain assessments for 2 of 3 (Patient #1 and #2) sampled adult patients seen in the Emergency Department.

The findings included:

1. Review of the Pain Management Program Policy revealed, "...To promote...Interdisciplinary (patient, physician, nurse...) collaboration and problem solving...Healthcare professionals will...demonstrate at least basic pain assessment skills, and provide pain interventions in a prompt caring fashion...Pain should be assessed by physicians and nurses as primary implementers of the pain management plan...Assessment and treatment of pain will be communicated using written documentation as well as verbal report. Pain intensity and pain, as reported...will be assessed and documented...with each new report of pain"

2. Medical record review for Patient #1 revealed the patient presented to the hospital's ED via ambulance on 4/1/2021 at 2:08 PM with chief complaints of altered mental status, lethargic, not eating. Patient #1 had an active diagnosis of Stage 3-4 Pancreatic Cancer.

Review of the emergency room initial Nursing assessment revealed an initial pain assessment was completed at dated 4/1/2021 at 2:11 PM with no complaints of pain at that time.

Review of the ED documentation revealed no pain assessments were completed and no pain medication was administered to Patient #1 for approximately 19 hours.

Patient #1 remained in the ED on 4/2/2021 at approximately 8:57 AM when the second (2nd) pain assessment was completed. Patient #1 stated a pain level of 8 (pain scale 0-10 with 8-10 being severe pain). Patient #1 was administered Hydromorphone (pain medication) 0.5 mg (milligrams) IV (intravenous) push at 8:57 AM.

In an interview on 5/3/2021 at 3:02 PM, the Nurse Manager of ED was asked if it was acceptable practice for a Registered Nurse to hold pain medication based on the possibility of lowering a blood pressure and not notifying the physician of the patient's complaint of pain. The Nurse Manager of ED stated, "No." The Nurse Manager of the ED revealed she did not counsel Registered Nurse (RN) #2 regarding the nurse's decision to hold pain medication.

In an interview on 5/3/2021 at 3:02 PM, the Director of ED confirmed she was made aware of Nurse #2's decision to hold pain medication for Patient #1 because it could drop the blood pressure. The Director of ED confirmed it was during a telephone interview when RN #2 made her aware. The Director of ED confirmed RN #2 did not notify the physician Patient #1 was complaining of pain or that she made the decision to hold pain medication due to the possibility the medication could initiate a drop in Patient #1's blood pressure. The Director of ED confirmed a verbal counseling was done with RN #2. The hospital was unable to provide any written documentation of the verbal counseling session. The Director of ED revealed she reviewed Patient #1's medical record but was unable to remember if there were any pain assessments completed.

During a telephone interview with the complainant on 5/5/2021 at 12:22 PM, the complainant confirmed the family asked the ED nursing staff multiple times for pain medication for Patient #1. The complainant revealed the family was told by a nurse that no pain medication could be administered because it would lower Patient #1's blood pressure. The complainant confirmed no nurses or physicians assessed Patient #1 for pain and Patient #1 was in the ED for approximately 19 hours with no pain medication administered.

3. Medical record review for Patient #2 revealed the patient presented to the hospital's ED on 3/19/2021 at 10:28 AM via ambulance with chief complaint of Altered Mental Status, Hypoglycemia and Fatigue.
Patient #2 was morbidly obese and placed on an ED stretcher.

Review of the ED pain assessments revealed an initial pain assessment was completed on 3/19/2021 at 10:26 AM for Patient #2 with no complaints of pain at that time. A 2nd pain assessment was completed approximately 22 hours later on 3/20/2021 at 8:00 AM and revealed "...Pain Present...Yes actual or suspected pain..." Review of the medication administration record revealed no pain medication was ordered by the physician or administered. A 3rd pain assessment was completed approximately 5.5 hours later on 3/20/2021 at 1:34 PM and revealed Patient #2 rated the pain at a level of 9 (pain scale 0-10 with 8-10 being severe pain). Review of the medication administration record revealed no pain medication was ordered by the physician or administered.

Patient #2 was transferred to an inpatient room at on 3/20/2021 at approximately 5:00 PM. (Approximately 29 hours after Patient #2 presented to the hospital's ED for treatment).

During a telephone interview on 5/5/2021 beginning at 2:04 PM, Patient #2 confirmed asking for pain medication and for assistance multiple times. Patient #2 stated he never received any pain medication during the ED stay and the nursing staff was "extremely rude and inconsiderate" and would not assist with his needs.

Based on record review and interview, the hospital failed to ensure the nursing staff developed and implemented a nursing care plan that reflected patient care to be provided in accordance with the medical care prescribed for 1 of 3 (Patient #3) sampled adult patients reviewed.

The findings included:

Medical record review revealed Patient #3 was admitted to the hospital on 3/6/2021 - 3/9/2021 with diagnoses that included Acute Stroke, Bilateral lung infiltrates and Hypercalcemia.

Review of the physician orders dated 3/6/2021 revealed Patient #3 was to have a Neurological Assessment (Neurological Checks) every 4 hours for 24 hours.
Record review revealed there was no documentation the nursing staff performed the neurological checks as prescribed.

In an interview on 4/30/2021 at 1:00 PM in the Quality Assurance Department, the Quality Coordinator verified there was no neurological check policy for the hospital and the neurological checks were not performed as prescribed.