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Based on facility policy review, medical record review and staff interview, the facility's nursing staff failed to evaluate pain assessment in 2 of 4 sampled patients in the facility's emergency department that received pain medication (Patient #9).

Findings include:

A review on 03/21/2012 of the facility's policy and procedure "Pain Identification and Management Of" (revised 01/13/2011) revealed "The HealthCare team will assess the patient's pain and provide interventions according to the patient's need, age, developmental level, maturation process and cultural response. The patient can expect: assessment and reassessment of pain based upon his/her individualized plan of care. Frequency of pain assessment: Unless otherwise indicated by patient's plan of care, pain should be assessed following pharmalogical intervention.

A closed medical record review on 03/21/2012 for patient #9 a 21 year old female, revealed that the patient presented to the facility's Emergency Department on 02/07/2012 at 0936 with a complaint of "Chronic Headache and Neck Pain." The review of the medical record revealed that the patient reported her pain as rated "8" on a scale of 1-10 with 10 being the highest level. The review revealed that the patient was administered the pain medications "Toradol" 30 milligrams Intravenously on 02/07/2012 at 1123 and "Nubain" 10 milligrams Intravenously at 1122 by the facility's registered nurse assigned to the patient. The review of the patient's medical record revealed that she was discharged home from the facility's Emergency Department on 02/07/2012 at 1414 (total of 2 hours and 52 minutes after pain medication administered) without any pain reassessment from the facility's nursing staff.

An interview on 03/21/2012 at 1430 with the facility's registered nurse assigned to patient #9 revealed that the patient was administered the medications "Toradol and Nubain" for her reports of pain. The interview further revealed that no documentation was found in the patient's medical record where her pain was assessed before she was discharged home. "We did not document any nursing assessment of her pain except before she was given the medications. We should by our policy document a reassessment."

Based on facility policy review, medical record review, and staff interview, the facility's nursing staff failed to administer physician ordered medications according to the facility's policy and procedure for medication administration in 1 of 4 sampled emergency department patients that were administered medications (Patient #9,7)

Findings include:

A review on 03/21/2012 of the facility's policy and procedure "Medication Administration" (revised 05/12/2011) revealed "Administration..4..Medications shall be considered to be "on time" if given 30 minutes before or 30 minutes after the standard administration time." The review further revealed "STAT orders..1. One time STAT medications should be given within 15 minutes."

1. A closed medical record review on 03/21/2012 for patient #9 a 21 year old female, revealed that the patient presented to the facility's Emergency Department on 02/07/2012 at 0936 with a complaint of "Chronic Headache and Neck Pain." The review of the patient's medical record revealed physician orders for the medications of "Toradol 30 milligrams Intravenously push once STAT and Nubain 10 milligrams Intravenously push once STAT both on 02/07/2012 at 0959. The review revealed that the facility's registered nurse assigned to the patient administered the medications "Toradol" 30 milligrams Intravenously on 02/07/2012 at 1123 (total of 1 hour and 23 minutes later) and "Nubain" 10 milligrams Intravenously at 1122 (total of 1 hour and 24 minutes later). The review revealed that the patient's STAT medications were not administered within 15 minutes as per the facility's policy and procedure for medication administration.

An interview on 03/21/2012 at 1430 with the facility's registered nurse assigned to patient #9 revealed that the medications were not given as ordered for STAT physician orders. We try to give them as soon as possible, but when physicians write the STAT orders, it is not always possible to give them within 15 minutes.

2. A closed medical record review on 03/21/2012 for patient #7 a 17 year old male, revealed that the patient presented to the facility's Emergency Department on 01/23/2012 at 1506 with a complaint of "Acute Headache." The review of the patient's medical record revealed physician orders for the medications of "Toradol 30 milligrams Intravenously push once STAT on 01/23/2012 at 1639. The record revealed that the facility's registered nurse assigned to the patient administered the medication on 01/23/2012 at 1715 (total of 36 minutes later). The review revealed that the patient's STAT medication was not administered within 15 minutes as per the facility's policy and procedure for medication administration.

An interview on 03/21/2012 at 1510 with the facility's Emergency Department Clinical Coordinator revealed that the medications were not given as ordered for STAT physician orders. The interview revealed that the physicians put the orders in for STAT medications and that does require, by policy to administer the medication within 15 minutes.


Reference NC00078460.