HospitalInspections.org

Based on interview and record review, the hospital failed to ensure one of three sampled patients (Patient 1) received care in a safe setting as evidenced by:

1. Patient 1's pain was not managed as per the hospital's P&P as evidenced by:

a. The ED RN failed to provide intervention for Patient 1's pain level of 5 out of 10.

b. The nursing staff failed to assess and reassess Patient 1's pain level before and after the administration of pain medications.

c. The nursing staff failed to ensure Patient 1's pain was managed to maintain Patient 1's goal pain level.

2. The physician failed to complete a medication reconciliation upon admission for Patient 1 as per the hospital's P&P.

3. A STAT brain MRI ordered by the physician for Patient 1, was not performed as per the hospital's P&P.

These failures posed an increased risk of substandard health outcomes for the patient by not addressing the patient care needs timely.

Findings:

Review of Patient 1's closed medical record was conducted on 7/16/25.

1. Review of the hospital's P&P titled Pain Assessment and Management Policy reviewed date 2/13/25, showed in part:

* Policy: Patients indicating pain upon screening shall be assessed further for pain. Patients shall be treated for pain and other related symptoms if they report pain interfering with function anytime during their hospital stay or visit. Patients responses to pain intervention shall be evaluated and documented in a timely manner.

* Definitions:

- Pain: defined as unpleasant sensory and emotional experience associated with actual or potential tissue damage or describing in terms of such damage.

- Numerical Rating Scale (NRS): Rates pain from 0, meaning no pain to 10, meaning the worst possible pain. 0: no pain, 1-3: mild pain, 4-6: moderate pain, 7-10: severe pain.

* Assessment and Reassessment:

- All patients will be assessed for the presence or absence of pain upon admission, point of entry to the Department of Emergency Medicine (triage) or Behavioral Health area, and clinic visit. This assessment will be documented in Electronic Health Record (EHR).

- Pain assessment and reassessment will continue while pain is being treated and with any new patient complaint of pain. This includes the evaluation of patient's satisfaction with pain management.

- The health care professional will assess the patient's pain utilizing the appropriate pain assessment tool, for example, patient's self-report (0-10 or faces) or the assessment tool for non-verbal patients.

- The initial patient assessment will be comprehensive based on the patient's self-reported pain score. Factors can include but are not limited to the following parameters: location, laterality, quality, pattern.

- The patient's acceptable level of pain will be documented in the medical record (if applicable).

- Pain assessment or reassessment shall be done as indicated by persistence of pain, initiation of potentially pain procedures, change in medical status, and/or after pharmacological intervention. The following will be reported immediately to the provider: uncontrollable pain, pain intervention that do not achieve patient's pain goal in a time frame appropriate to the intervention, new or worsening pain, and adverse effects of pain medication.

- Timing of pain reassessment, after intervention, will be appropriate for the modality or medication and route of admission. IV or IM medication shall be reassessed within 30 minutes post administration. Other medications (including but not limited to, by PO, SQ etc.) shall be assessed for no more than two hours post administration.

- In the Department of Emergency Medicine (DEM), pain will be assessed or reassessed as follows: at triage or initial nursing assessment if patient does not go through triage, reassessed minimum every eight hours from the original pain assessment or as needed if there is a change in patient condition.

* Interventions: Pain management will include any of the following:

- Pharmacologic: non-opioid - there is not a minimum or maximum number of medications which can be prescribed to the patient under the law.

- Non- pharmacologic pain management and/or CAM may be considered which included physical interventions, acupuncture, or cognitive behavior strategies.

- The provider should tailor pharmacological therapy to the individual medical needs of each patient. Multiple treatment modalities and rehabilitation programs may be necessary if the pain is complex or is associated with physical and psychological impairment.

* Documentation: All pain complaints, assessments, interventions, reassessments, plan of care, patient or family education, medication administration, and provider notification will be documented in EHR.

a. Review of Patient 1's medical record was conducted with the Nurse Educator on 7/16/25 at 1345 hours.

Patient 1's medical record showed the patient was admitted to the hospital's ED on 2/28/25 at 1600 hours, brought in by ambulance and complaining of generalized weakness after a fall sustained 5 days ago.

Review of the ED triage documentation showed on 2/28/25 at 1630 hours, Patient 1 complained of pain with the pain level of 5 out of 10 (or moderate pain) on the right shoulder.

The Nurse Educator was asked for the intervention provided to the patient for the pain level of 5 out of 10 on the right shoulder. The Nurse Educator stated there was no documentation of the intervention the ED RN provided to the patient to alleviate the right shoulder pain with the pain level of 5 out of 10.

Review of the ED RN's pain assessment for Patient 1's right shoulder on 2/28/25 showed the following:

- At 1820 hours, lidocaine topical (a medication used to prevent pain by blocking the signals at the nerve endings in the skin) and Tylenol (analgesic, a pain medication) 650 mg given orally. However, there was no documented evidence of assessment of the pain level.

- At 1830, 1853, and 1933 hours, the patient's pain level was 5 out of 10.
- At 2142 hours, the patient's pain level was 4 out of 10.
- At 2355 hours, the patient's pain level was 5 out of 10.

The Nurse Educator stated there was no documented evidence the RN provided non-pharmacological or pharmacological intervention for the patient's moderate pain of the right shoulder.

b. Review of the hospital's P&P titled Inpatient Care Documentation Guidelines review date 2/8/24, showed the policy guidelines was to provide a general overview of the minimum documentation requirements for the various adult inpatient areas. Dependent on patient condition and situation, documentation may be modified based upon response to interventions and/or physician's order.

- Patient assessment and monitoring requirement for Medical Surgical unit: minimum of four hours. Vital signs every four hours or as ordered by the physician. Pain assessment upon admission, onset or patient complaints of pain, before, during and after each procedure as indicated.

Review of Patient 1's medical record was conducted with the Nurse Educator.

Patient 1's medical record showed the patient was admitted to the Medical Surgical unit on 3/1/25 at 0512 hours. The pain assessment at 0518 hours showed the patient's pain level was 0 out of 10 and the patient's acceptable pain level was 2 out of 10.

Review of Patient 1's pain assessment, reassessment and intervention showed the following:

- On 3/1/25 at 0800 hours, Patient 1's pain level was 0 out of 10. At 1200 hours, there was no documentation the patient's pain was assessed. At 1600 hours, the patient complained of back pain with the pain level at 10 out of 10; the patient was given Tylenol 650 mg for pain. The pain was reassessed at 1700 hours and the patient's pain level was 3 out of 10; there was no documented intervention provided to the patient.

- On 3/2/25 at 0805 hours, Patient 1 complained of generalized pain with the pain level of 6 out of 10; there was no documentation to show pharmacologic /non-pharmacologic intervention was provided to the patient. At 0940 hours, the patient complained of generalized pain with the pain level of 7 out of 10 and the patient was medicated with ketorolac (a nonsteroidal anti-inflamatory drug that used for pain relief) 15 mg IVP; however, there was no documentation of reassessment of the patient's pain. At 1227 hours, the patient was given oxycodone (an opioid pain medication) 2.5 mg PO; however, there was no level of pain assessment documented and reassessment of pain after the medication intervention was provided to the patient. In addition, the assessment of pain was blank four hours after. At 2056 hours, the patient reported pain level of 10 out of 10 on the right shoulder and was medicated with Tylenol 650 mg PO. At 0022 hours (after 3 hours and 26 minutes), The pain was reassessed, and the patient's pain level was 0 out of 10.

- On 3/3/25 at 0142 hours, Patient 1 was given oxycodone 2.5 mg PO without documentation of pain level assessment. There was no documented assessment of pain from 0210 hours to 0904 hours (or approximately 7 hours). There was no documented pain assessment from 0944 hours to 1556 hours (6 hours and 12 minutes).

- On 3/4/25, there was no documented pain assessment from 1704 hours to 2340 hours (6 hours and 36 minutes).

- On 3/6/25, there was no documented pain assessment from 1823 hours to 0020 hours (5 hours and 57 minutes).

- On 3/8/25 at 0018 hours and 0607 hours, the patient was given oxycodone 2.5 mg PO; however, there was no pain level assessment for the indication of pain medication and reassessment after the pain medication was given.

The Nurse Educator stated she believed pain assessment was performed when every vital sign was taken. The Nurse Educator stated the NAs took the vital signs and asked the patient for the presence of pain, then the NAs informed the RN of the patient's presence of pain; the RN would assess the patient's pain.

The Nurse Educator verified the above findings.

c. Review of the hospital's P&P titled Patient Rights and Responsibilities review date 2/13/25, showed the hospital observes and respects the rights of patients and staff at all times and provides patients and visitors with information as to their rights and responsibilities. Patients have the right to considerate and respectful care. Patients have the right to pain management.

Review of Patient 1's medical record was conducted with the Nurse Educator.

Review of the orders for Patient 1's pain medications showed the following:

- On 3/1/25 at 1521 hours, the order showed to give Tylenol 650 mg PO every six hours PRN for pain. The order did not show the indication for specific level of pain.

- On 3/1/25 1605 hours, the order showed to give oxycodone 2.5 mg PO every eight hours PRN for pain not relieved by non-opioid medications.

- On 3/3/25 at 0803 hours, the order showed to give Dilaudid (an opioid pain medication) 0.2 mg IV every six hours PRN for pain (5-10), for breakthrough pain. The order was discontinued on 3/10/25.

- On 3/1/25 at 1607 hours, the order showed to give diclofenac (a nonsteroidal anti-inflammatory drugs used to treat pain) 1% topical gel, topical application QID PRN for pain.

- On 3/4/25 at 1400 hours, the order showed to give lidocaine 5% topical cream, 1 application TID.

Random review of Patient 1's MAR, showed Tylenol 650 mg po was given on the following:

- On 3/4/25 at 0842, 1547, and 2353 hours.
- On 3/5/25 at 2356 hours.
- On 3/6/25 at 0522 and 1153 hours.
- On 3/7/25 at 0020, 0613, and 2119 hours.
- On 3/8/25 at 1035 and 1908 hours.
- On 3/9/25 at 1633 hours.

Review of Patient 1's pain assessment, administration of oxycodone 2.5 mg PO, and reassessment after intervention showed the following:

- On 3/3/25 at 0142 hours, the patient was given oxycodone 2.5 mg; however, there was no pain level assessment documented. At 0215 hours, the patient's pain level was reassessed, and the patient's pain level was 0 out of 10. At 1556 hours, oxycodone was given for pain level of 10 out of 10 and the patient was reassessed at 1718 hours, with the pain level of 0 out of 10.

- On 3/4/25 at 0055 hours, oxycodone was given for pain level of 10 out of 10. The patient was reassessed at 0155 hours, with the pain level of 2 out of 10. At 0531 hours, oxycodone was given for 10 out of 10 one-time dose. The patient was reassessed at 0631 hours with the pain level 0 out of 10. Oxycodone was given to the patient at 1358 hours, for the pain level of 10 out of 10 pain level and the patient was reassessed at 1458 hours with the pain level of 0 out of 10. Oxycodone was given at 2340 hours for pain level of 10 out of 10.

- On 3/5/25 at 0040 hours, the reassessed pain level was at 2 out of 10. Oxycodone was given at 0814 hours for the pain level of 10 out of 10 and the patient's pain level was reassessed at 0902 hours and was 0 out of 10. Oxycodone was given at 1637 hours for pain level of 10 out of 10 and the patient's pain level was reassessed at 1713 hours and was 0 out of 10.

- On 3/6/25 at 0139 hours, oxycodone was given to the patient for the pain level of 9 out of 10 and the patient's pain level was reassessed at 0225 hours and was 0 out of 10. Oxycodone was given at 1522 hours, for pain level of 8 out of 10 and the patient's pain level was reassessed at 1622 hours and was 2 out of 10.

- On 3/7/25 at 0127 hours, oxycodone was given to the patient for the pain level of 5 out of 10 and the patient's pain level was reassessed at 0227 hours and was 0 out of 10. Oxycodone was given at 1024 hours, for the pain level of 7 out of 10 and the patient's pain level was reassessed at 1124 hours and was 2 out of 10. Oxycodone was given at 1826 hour for the pain level of 8 out of 10; there was no pain reassessment after the medication was given.

- On 3/8/25 at 0018 hours, oxycodone was given without pain level assessment and reassessment documented. At 0607 hours, oxycodone was given without documented pain level assessment and reassessment. At 1258 hours, oxycodone was given for the pain level 10 out of 10 and the patient's pain level was reassessed at 1358 hours and was 0 out of 10. At 1950 hours, oxycodone was given for the pain level 7 out of 10; there was no reassessment of pain level.

Review of Patient 2's pain assessment, administration of Dilaudid 0.2 mg IV PRN for breakthrough pain, and reassessment after the medication showed the following:

- On 3/3/25 at 0904 hours, Dilaudid 0.2 mg IV was given for the pain level 10 out of 10 and the patient's pain level was reassessed at 0944 hours and was 0 out of 10. Dilaudid was given for pain at 2117 hours, for the pain level of 10 out of 10 and the patient's pain level was reassessed at 2132 hours and was 2 out of 10.

- On 3/4/25 at 0327 hours, Dilaudid 0.2 mg IV was given for the pain level of 10 out of 10 and the patient's pain level was reassessed at 0342 hours and was pain level 2 out of 10. Dilaudid was given at 1005 hours for the pain level of 10 out of 10 and the patient's pain level was reassessed at 1020 hours and was 2 out of 10. Dilaudid was given at 1649 hours for the pain level of 10 out of 10 and the patient's pain level was reassessed at 1704 hours and was 0 out of 10.

- On 3/5/25 at 0320 hours, Dilaudid 0.2 mg IV was given for the pain level of 10 out of 10 and the patient's pain level was reassessed at 0335 hours and was 2 out of 10. Dilaudid was given at 1135 hours for the pain level of 10 out of 10 and the patient's pain level was reassessed at 1232 hours and was 0 out of 10. Dilaudid was given at 2112 hours for the pain level of 10 out of 10 and the patient's pain level was reassessed at 2155 hours and was 2 out of 10.

- On 3/6/25 at 0827 hours, Dilaudid 0.2 mg IV was given for the pain level of 7 out of 10. At 0842 hours, the patient's pain level was reassessed and was 2 out of 10. Dilaudid was given at 1808 hours for the pain level of 7 out of 10 and the patient's pain level was reassessed at 1823 hours and was 2 out of 10.

- On 3/7/25 at 1442 hours, Dilaudid 0.2 mg IV was given for the pain level of 10 out of 10 and the patient's pain level was reassessed at 1457 hours and was 0 out of 10.

Patient 1's pain level assessment from 3/1/25 to 3/8/25 showed the patient's pain assessment levels were generally 10 out of 10 (severe) before the PRN pain medications were administered. The patient's trend of pain level did not show the pain level of 2 out of 10 was maintained despite Patient 1 receiving the PRN pain medications.

On 7/17/25 at 1510 hours, the Nurse Educator was asked what the expectation from the RNs was when the patient's desired pain goal level of 2 out of 10 was not maintained and prevent the pain level from escalating at 10 out of 10. The Nurse Educator stated the RN should call the physician to obtain an order for pain medication to be administered on a scheduled regular basis not as a PRN to maintain the desired patient's goal level of pain 2 out of 10 and prevent the pain level increasing up to 10.

The Nurse Educator verified the findings.

2. Review of the hospital's P&P tilted Medication Reconciliation reviewed date 8/8/22, showed:

* Policy: Providers (physicians and NPs) shall adhere to medication reconciliation procedures to maximize safe medication practices at points of care and care transitions. Clinicians shall make a good faith effort to obtain accurate medication information from the patient and or other sources and accurate medication information from the patient and/or other sources and document this information in a useful way to those who manage medications.

* Procedure: Inpatient: Admission: Responsible healthcare providers will record the current list of medications the patient is taking on admission. The list contains name, dose, frequency, and route, whenever possible based on the information available. The primary means for obtaining the list is the patient/parent/caregiver interview, the Electronic Medical Record (EMR), and any other outside records. The medication list will be reviewed and compared to admission orders written for duplications, omissions, and interactions.

Review of Patient 1's H&P examination dated 3/1/25 at 0248 hours, showed Patient 1's family accompanied the patient at the bedside. The patient reported having a mechanical fall about five days ago, tripping over her feet and was unable to get up. Per family, only known medical history of breast cancer; otherwise, unclear past medical history or medications. The patient reportedly saw several doctors closer to the patient's home (a different city) unknown where. The patient lived by themselves at home, was independent with all ADLs. The sections of Ongoing and Historical Problem List/Past Medical history showed no qualifying data. The section of Medications showed no active home medications. The Emergency contact list was Family Member 1.

Review of Patient 1's H&P examination dated 3/1/25 at 1842 hours, showed an addendum update showing Family Member 2 was at bedside, collateral obtained... Corroborates story told to us by the patient fell, was able to crawl to phone after some time and text Family Member 3 to call 911, and Family Member 3 called the patient's neighbor to check on the patient.

Review of the Internal Medicine Progress Note dated 3/10/25, showed the Assessment and Plan section showing Patient 1 had back pain, shoulder pain, history of RA, discovered later in the hospital stay that the patient had history of RA, on methotrexate (anti-inflammatory and immunosuppressant), Plaquenil (anti rheumatic medication - reduced pain, swelling, and stiffness in joints. lessen inflammation) with folate supplementation at home.

There was no documented evidence that Patient 1 received home medication for RA.

The Nurse Educator stated she could not find the medication reconciliation for Patient 1 upon admission to the hospital.


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3. Review of the hospital's P&P titled MRI Hours of Operation and Off-Hours MRIS dated 9/21/24, showed "Policy: MRI Scope of Service and Workflow for Emergent MRI...The routine MRI daily hours of operations are Mon-Fri 7:00 am to 12:00 am (midnight) for inpatients...and outpatients...After hours, the referring physician will place the order for the MRI and contact either the radiologist on duty in the hospital or the neuroradiologist on call. If approved, the radiologist or their representative will contact the MRI technologist on call..."

Review of the Emergency Documentation dated 2/28/25 at 1813 hours, showed Patient 1 was brought to the ED by ambulance for a fall and generalized weakness on 2/28/25.

Review of the MRI order dated 3/1/25, showed a STAT MRI of the brain with and without contrast was electronically ordered and signed on 3/1/25 at 0122 hours (After hours). The relevant history documented was "dysarthria 2 days ago." The MRI order showed RN 2 reviewed the order at 0129 hours on 3/1/25.

On 7/17/25 at 1343 hours, an interview and concurrent review of Exhibit B Attachment A-6 TAT Expectation for radiology was conducted with the Risk Management.

The Risk Management stated Exhibit B Attachment A-6 TAT Expectation for radiology showed the TAT for a STAT MRI order was one hour.

Review of the medical record did not show documentation that explained why the MRI was not performed STAT, as ordered.

Review of Patient 1's medical record did not show that the MRI Scope of Service and Workflow for Emergency MRI was implemented as per the hospital's P&P for Patient 1's STAT MRI order, that was placed after hours.

On 7/17/25 at 1602 hours, the Risk Management confirmed the findings.

Based on observation, interview, and record review, the hospital failed to ensure the hospital's P&P for Restraints was implemented for one of three sampled patients (Patient 2). This failure posed an increased risk for the violation of patient's rights.

Findings:

Review of the hospital's P&P titled Restraints and or Seclusion reviewed on 3/4/25 showed under the section for Definitions: Restraints: Any manual method or physical or mechanical device, material, or equipment, that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. Types of Physical Restraints: ...Four side rails.

The section for Ordering Restraints or Seclusion: A LIP must order the restraints and or seclusion. Within one hour after the initiation of restraints and or seclusion for violent behavior management. Orders for restraints of patient with non-violent behavior management needs are limited to one calendar day.... In an emergency. A RN may initiate use of restraints and or seclusion before an order is obtained from an LIP. The LIP responsible for the care of the patient must be consulted as soon as possible within one hour of restraints or seclusion.

On 7/16/25 at 1055 hours, an observation of Patient 2 was conducted on the Medical/Surgical Floor 4 D, accompanied by the Nurse Manager. Patient 2 was observed lying in bed asleep, with the four side rails up. NA 1 was observed sitting outside Patient 2's room door. NA 1 stated she was the sitter for Patient 2. NA 1 stated Patient 2 tried to pull his catheter, get out of bed, exhibited aggressive behavior and attempted to hit the staff. NA 1 stated the four siderails were up to prevent falls. NA 1 stated Patient 2 was on isolation precautions for VRE and CRP, and she would need to put on the isolation PPE before entering Patient 2's room, which would delay from stopping Patient 2 from pulling his catheter and from falling out of bed.

On 7/17/25 at 1440 hours, review of Patient 2's medical record was conducted with the Nursing Educator. The Nurse Educator stated there was no physician's order for Patient 2's four siderails to be up. The Nursing Educator stated when the four siderails were up, it was considered as restraints, and there was no P&P for the use four side rails up to prevent falls.

The above finding was shared with the Nurse Educator.