HospitalInspections.org

Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary care to one of four sampled patients (Patient 1) in the ED as evidenced by:

1. The nursing staff failed to perform the reassessment including the vital signs for Patient 1 as per the hospital's P&P.

2. The nursing staff failed to perform the pain reassessment after the pain medication was administered for Patient 1 as per the hospital's P&P.

These failures had the potential to result in substandard care to the patients.

Findings:

On 5/20/25, Patient 1's closed medical record was reviewed. Patient 1's medical record showed Patient 1 arrived in the ED on 5/3/25 at 1240 hours, and was discharged from the ED on 5/3/25 at 1704 hours.

1. Review of the hospital's P&P titled Assessment- Reassessment, Patient dated 3/2/23, showed the following:

* Repeat vital signs to be measured and documented as follows:

- For Level III, at least every 60 minutes with the understanding that more frequent assessment is often indicated and will be expected until vital signs are stable. If vital signs are stable, they will be measured every 30 to 60 minutes until patient is assessed at a higher acuity level.

* The nurse assigned to the patient is responsible for continual assessing/reassessing of the patient's condition:

- Obtaining and documenting vital signs per patient acuity or condition

- Abnormal vital signs will be checked prior to discharge

- Persistent abnormalities (patient status and/or vital signs) will be reported to physician prior to patient being discharged from the ED

- Discharge vital signs and patient condition will be documented on all patients.

Review of the Patient Care Timeline for Patient 1 dated 5/3/25, showed the following:

* At 1241 hours, Patient 1's vital signs were measured.
* At 1246 hours, Patient 1's acuity level was 3.
* At 1529 hours, the shift assessment was performed.
* At 1704 hours, Patient 1 was discharged from the ED.

There was no documented evidence to show Patient 1's vital signs were assessed at least every 60 minutes as per the hospital's P&P.

On 5/20/25 at 1330 hours, the Director of ED verified the findings.

2. Review of the hospital's P&P titled Pain Management dated 12/5/24, showed the goal is to maintain a pain rating of the patient's own comfort level goal. This may be documented with the pain intensity score, by indicating intervention effective, or by patient statement that they do not need treatment for pain. Pain will be reassessed after each pain management intervention.

Review of the Patient Care Timeline for Patient 1 dated 5/3/25, showed the following:

* At 1241 hours, Patient 1 complained of pain to the right wrist with the pain score of five out of 10 (0 being no pain and 10 being the worst pain). Patient 1 stated pain goal was no pain.
* At 1246 hours, Patient 1's acuity level was 3.
* At 1301 hours, the ED Provider evaluated the patient.
* At 1419 hours, acetaminophen (a pain medication) tablet 1,000 mg was ordered.
* At 1517 hours, Patient 1's pain score was five out of 10.
* At 1518 hours, Patient 1 received acetaminophen tablet 1,000 mg by mouth.
* At 1704 hours, Patient 1 was discharged from the ED

However, further review of Patient 1's medical record failed to show Patient 1's pain reassessment after the pain medication was administered to the patients.

On 5/20/25 at 1330 hours, the Director of ED verified the above findings.