HospitalInspections.org

Based on policy review, medical record review, and staff interviews the facility staff failed to assess and reassess a patient's pain in the emergency department (ED) for 4 of 10 patients (Patient #2, 3, 5 and 7), failed to reassess patient's vital signs in the ED for 2 of 10 patients (Patient #3 and #7), and failed to document a nursing assessment on patients in the emergency department for 3 of 10 patients (Patient #2, 3, and 4).

The findings included:

1. Review on 02/18/2020 of a policy titled "Pain Assessment and Management" last revised/reviewed 11/2019 revealed "...A. Pain Assessment When the patient presents to the organization the patient is screened for the presence of acute and/or persistent pain...2. Assessment/reassessment occurs: a) Before and after implementing the treatment plan which may include both pharmacological and non-pharmacological interventions. b) Within 90-minutes after a pharmacological intervention and includes scheduled and as needed (PRN) analgesics. When an analgesic has been given in an outpatient area reassessment occurs within 90 minutes or prior to discharge (whichever occurs first)..."

a. Closed medical record review on 02/18/2020 of Patient #2 revealed a 55-year-old male who arrived to the ED on 01/07/2020 at 0701 with a chief complaint of chest pain. Review of the triage notes revealed "...Chest Pain started last night took 81mg (milligrams) x's3 (as written) at home. States he feels clammy and has had a cough denies fever..." Review revealed Patient #2 was discharged home at 1000. Review failed to reveal a pain assessment documented during Patient #2's ED visit.

Interview on 02/18/2020 at 1525 with RN #3 (Registered Nurse) revealed he took care of Patient #2 but did not recall him. Interview revealed RN #3 completed pain assessments on all patients he took care of, but he might not have documented it. Interview revealed pain assessments were supposed to be done on all patients.

Interview on 02/19/2020 at 1145 with the Director of the ED revealed pain assessments should be done with vital signs at triage, before pain medications, and within 90 minutes after a pain intervention.

b. Closed medical record review on 02/18/2020 of Patient #3 revealed a 73-year-old female who arrived to the ED on 01/28/2020 at 1444 with a chief complaint of hip pain. Review of the triage documentation revealed a pain assessment of 6 out of 10 documented (0-10 pain scale where 0 means no pain and 10 means the worst pain). Review revealed Patient #3 "Left Without Being Seen" on 01/29/2020 at 0015 (9 hours and 31 minutes after her arrival). Review failed to reveal any other pain assessments documented.

Interview on 02/18/2020 at 1515 with RN #1 revealed she recalled Patient #3. Interview revealed she triaged Patient #3. Interview revealed RN #1 generally tried to reassess patient's including pain every four hours, but it was "ridiculous" that day there were four other patients waiting to be triaged.

Interview on 02/19/2020 at 1145 with the Director of the ED revealed pain assessments should be done with vital signs at triage, before pain medications, and within 90 minutes after a pain intervention. Interview revealed patients should be assessed for pain every 4 hours.

c. Closed medical record review on 02/18/2020 of Patient #5 revealed a 71-year-old female who arrived to the ED on 12/05/2019 at 2205 with a chief complaint of abdominal pain. Review revealed at 2307 Patient #5 was given 4mg of IV (intravenous) morphine (pain medication) and no pain assessment was documented before the pharmacological intervention. Review revealed at 0008 Patient #5's pain was 8 out of 10. Review revealed at 0033 Patient #5 was given 0.5 mg of IV dilaudid (pain medication) and a pain assessment documented at 0033 was 9 out of 10. Review revealed no other pain assessment documented within 90 minutes after the dilaudid administration or prior to discharge. Review revealed Patient #5 was discharged at 0206 (93 minutes after Patient #5 was given dilaudid).

Interview on 02/19/2020 at 1145 with the Director of the ED revealed pain assessments should be done with vital signs at triage, before pain medications, and within 90 minutes after a pain intervention.

d. Open medical record review on 02/19/2020 of Patient #7 revealed a 52-year-old female who arrived to the ED on 02/18/2020 at 0703 with a chief complaint of "dog bite." Review revealed at 0841 Patient #7 was given 600mg of Ibuprofen oral and a pain assessment documented at 0841 was 5 out of 10. Review revealed a pain reassessment at 1155 (194 minutes after the Ibuprofen administration) was documented as "No/denies pain." Review revealed Patient #7 was discharged at 1300.

Interview on 02/19/2020 at 1145 with the Director of the ED revealed pain assessments should be done with vital signs at triage, before pain medications, and within 90 minutes after a pain intervention.

2. Review on 02/18/2020 of a policy titled "Assessment/Reassessment" last revised/reviewed 12/2019 revealed "...Emergency Department (ED) Adult and Pediatric Patients are triaged in a timely manner as patient condition warrants. Initial focused assessment on arrival to the Emergency Department. Focused reassessments, including vital signs, every 4 hours (+/- 30 minutes) and/or as patient's condition warrants. For any unexpected return visit to the Emergency Department within 24 hours, the patient needs to be re-assessed by the ED Physician prior to discharge..."

a. Closed medical record review on 02/18/2020 of Patient #3 revealed a 73-year-old female who arrived to the ED on 01/28/2020 at 1444 with a chief complaint of hip pain. Review revealed vital signs obtained at 1508 during triage were temperature 98.2 degrees Fahrenheit, heart rate 75, respirations 18, blood pressure 140/63 and oxygen saturation 99% on 3L (liters) of oxygen. Review revealed Patient #3 "Left Without Being Seen" on 01/29/2020 at 0015 (9 hours and 7 minutes after the initial set of vital signs). Review failed to reveal any other vital signs documented for Patient #3.

Interview on 02/18/2020 at 1515 with RN #1 revealed she recalled Patient #3. Interview revealed she triaged Patient #3. Interview revealed RN #1 generally tried to reassess patient's including vital signs every four hours, but it was "ridiculous" that day there were four other patients waiting to be triaged.

Interview on 02/19/2020 at 1145 with the Director of the ED revealed vital signs should be completed at triage and every four hours or more frequently depending on a patient's acuity.

b. Open medical record review on 02/19/2020 of Patient #7 revealed a 52-year-old female who arrived to the ED on 02/18/2020 at 0703 with a chief complaint of "dog bite." Review revealed vital signs obtained at 0707 during triage were temperature 97.9, heart rate 118, respirations 20, blood pressure 153/94 and oxygen saturation 98% on room air. Review failed to reveal another set of vital signs obtained within 4 hours. Review revealed a set of vital signs obtained at 1300 (5 hours and 53 minutes after the first set of vital signs) documented as heart rate 90, respirations 18, and blood pressure 156/84. Review revealed Patient #7 was discharged at 1300.

Interview on 02/19/2020 at 1145 with the Director of the ED revealed vital signs should be completed at triage and every four hours or more frequently depending on a patient's acuity.

3. Review on 02/18/2020 of a policy titled "Assessment/Reassessment" last revised/reviewed 12/2019 revealed "...Emergency Department (ED) Adult and Pediatric Patients are triaged in a timely manner as patient condition warrants. Initial focused assessment on arrival to the Emergency Department. Focused reassessments, including vital signs, every 4 hours (+/- 30 minutes) and/or as patient's condition warrants. For any unexpected return visit to the Emergency Department within 24 hours, the patient needs to be re-assessed by the ED Physician prior to discharge..."

Review on 02/18/2020 of a policy titled "ED Triage" last revised/reviewed 01/2018 revealed "...D. Triage Assessment may include but is not limited to an across the room, rapid and/or comprehensive assessment: 1. Across the room assessment should be completed in 30 seconds or less to determine life threatening illness or injuries. i. General appearance, airway, breathing, circulation, and disability...3. Collect pertinent objective data specific to the patient condition and complaints including but not limited to : i. Vital signs...iii. Assess pain utilizing appropriate pain scales...5. If a rapid assessment is initiated the comprehensive assessment will be completed by the primary nurse...10.. The primary RN (Registered Nurse) is responsible for reviewing and/or completing the triage assessment and will complete the nursing assessment during the course of the patient's care..."

a. Closed medical record review on 02/18/2020 of Patient #2 revealed a 55-year-old male who arrived to the ED on 01/07/2020 at 0701 with a chief complaint of chest pain. Review of the triage notes revealed "...Chest Pain started last night took 81mg x's3 (as written) at home. States he feels clammy and has had a cough denies fever..." Review revealed Patient #2 was discharged home at 1000. Review failed to reveal a nursing assessment documented during Patient #2's ED visit.

Interview on 02/18/2020 at 1525 with RN #3 revealed he took care of Patient #2 but did not recall him. Interview revealed RN #3 completed nursing assessments on all patients he took care of, but he might have not documented it. Interview revealed nursing assessments were supposed to be done on all patients. Interview revealed patients were triaged and then a more in-depth focused nursing assessment was completed by the primary nurse.

Interview on 02/18/2020 at 1500 with NM #1 (Nurse Manager) revealed there should be a triage assessment and additional focused nursing assessment for each patient.

Interview on 02/19/2020 at 1145 with the Director of the ED revealed a triage assessment was done by the triage nurse who could complete a rapid triage depending on how many patients were waiting to be triaged. Then a focused nursing assessment was completed once patients were in the back specific to the patient's chief complaint.

b. Closed medical record review on 02/18/2020 of Patient #3 revealed a 73-year-old female who arrived to the ED on 01/28/2020 at 1444 with a chief complaint of hip pain. Review revealed Patient #3 was triaged at 1455. Review revealed Patient #3 "Left Without Being Seen" on 01/29/2020 at 0015. Review failed to reveal a nursing assessment documented during Patient #3's ED visit.

Interview on 02/18/2020 at 1515 with RN #1 revealed she recalled Patient #3. Interview revealed she triaged Patient #3. Interview revealed RN #1 generally tried to reassess patient's every four hours, but it was "ridiculous" that day there were four other patients waiting to be triaged.

Interview on 02/18/2020 at 1500 with NM #1 revealed there should be a triage assessment and additional focused nursing assessment for each patient.

Interview on 02/19/2020 at 1145 with the Director of the ED revealed a triage assessment was done by the triage nurse who could complete a rapid triage depending on how many patients were waiting to be triaged. Then a focused nursing assessment was completed once patients were in the back specific to the patient's chief complaint.

c. Closed medical record review on 02/18/2020 of Patient #4 revealed an 89-year-old male who arrived to the ED on 12/17/2019 with a chief complaint of "fall." Review of the triage notes revealed a focused assessment documented at 0235 that airway, breathing, circulation and disability were within defined limits. Review revealed Patient #4 was discharged at 0716 (4 hours and 41 minutes after the triage nursing assessment). Review failed to reveal any other nursing assessments documented.

Interview on 02/18/2020 at 1500 with NM #1 revealed there should be a triage assessment and additional nursing assessment for each patient.

Interview on 02/19/2020 at 1145 with the Director of the ED revealed a triage assessment was done by the triage nurse who could complete a rapid triage depending on how many patients were waiting to be triaged. Then a focused nursing assessment was completed once patients were in the back specific to the patient's chief complaint.

NC00160614