HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interviews the facility failed to document a pain reassessment for 1 (Patient 24) of 5 sampled patients discharged from the emergency department (ED). This failed practice has the potential to cause negative outcomes for all patients who present to the ED. There were 5,292 ED visits for FY 2023.

Findings are:

A. Review of policy titled Transfer and Emergency Exam (Effective 4/24) revealed Registered Nurse (RN) responsibilities included: Provide nursing care and document nursing assessments and interventions in the Electronic Medical Record (EMR) system and the ED Medication Record in accordance with ED documentation procedures.

B. Review of Patient 24's medical record (8/19/2024 at 3:12PM) revealed that Patient 24 arrived at the ED on 7/24/2024 at 1:15PM with a chief complaint of abdominal pain and a past medical history of a cesarean section (surgically remove baby from abdomen) 7 weeks prior. Triage vitals at 1:19 PM included Temperature 98F, Blood pressure 118/75, heart rate 87, Oxygen saturation 97% on room air. RN-B documented a pain score of 9/10 to Patient 24's abdomen on 7/24/2024 at 2:18PM and gave intravenous (IV) Morphine (a pain medication that goes through the vein) and IV Zofran (a medication to reduce or relieve nausea or vomiting that goes through the vein) at 2:19 PM. Patient 24's entire medical record lacked evidence of a documented pain reassessment prior to discharge at 4:16 PM.

C. Interview with RN-A (8/20/2024 at 3:37PM) confirmed that they did not re-assess Patient 24's pain prior to discharge on 7/24/2024.