HospitalInspections.org

Based on record review and interview the facility failed to ensure the medical record was complete by failing to document vital signs and an emergency severity index (ESI) on 1 of 10 Emergency Department patients triaged (Patient #12) and failed to include pain assessments and reassessments to determine pain control needs of 1 of 5 patients presenting with pain (Patient # 12) and in a total of 14 medical records reviewed.

Findings include:

Record review of policy "Triage" #8438596, last approved 8/13/2020 revealed a patient seeking medical care in the Emergency Department will be assessed using the "ESI Triage Algorithm" (emergency severity index).

Record review of policy "Patients Leaving Against Medical Advice/Elopement" #7652279, last approved 2/12/2020 under Competent Adult Patient(s) eloped/missing from the Facility (Unauthorized Departure) #2 revealed "Document the time the patient was first noticed missing in the medical record."

Record review of policy "Pain Management" #8071040, last revised 5/15/2020 revealed the facility "respects the patient's right to have their pain managed." Under Initial Assessment of Patients with Pain revealed "pain identified during screening includes a comprehensive pain assessment." Under #4 revealed "Patients will be assessed for pain at a minimum of once per shift" (8 hours). Under #5 revealed "Pain and the effectiveness of pain management interventions are reassessed and documented."

Review of Patient #1's medical record revealed Patient #1 was a 22-year-old who presented to the Emergency Department 9/20/2021 at 2:27 AM with a chief complaint of chest pain. On the form titled "Depart summary ED" dated 9/20/2021 at 5:10 AM under disposition revealed "Left Without Being Seen by Provider Staff" documented by Registered Nurse W. There was no documentation of vital signs or an ESI screen being completed.

On 11/03/2021 at 3:50 PM during interview with the Executive Director of Nursing (DON) D, DON D stated vitals signs need to be taken before an emergency severity index (ESI) triage score can be determined. DON D confirmed there were no vital signs or ESI score documented in Patient #1's medical record when s/he presented to the ED 9/20/2021 at 2:27 AM.

Review of Patient #12's medical record revealed Patient #12 was a 41-year-old who presented to the Emergency Department (ED)9/20/2021 at 2:09 AM with a chief complaint of chest and back pain. Pain assessment completed 9/20/2021 at 2:38 AM documented chest pain 8 out of a 1 to 10 pain scale (10 being most severe). No pain goal was documented, no pain medication was given. On 9/20/2021 at 5:03 AM (2 hours and 25 minutes later), Patient #12's pain was documented as a 9 (no location noted) and s/he was given oxycodone 15 mg immediate release tablet. S/he was not reassessed for pain again until 9/20/2021 at 2:56 PM (9 hours and 53 minutes later) when s/he scored it as a 4, with no pain location identified. Patient #12 was a "boarded" patient in the ED waiting for a bed placement until 9/20/2021 at 9:44 PM. On 9/21/2021 at 1:15 PM, it was documented Patient #12 had bilateral leg pain of 8 and s/he was given one tablet of oxycodone 5 mg for "pain-moderate". Patient #12 was discharged 9/21/2021 at 5:07 PM (3 hours later). There was no pain reassessment documented prior to discharge.

On 11/02/2021 at 4:10 PM during review of Patient #12's medical record with Emergency Department Manager E and Quality Coordinator (QC) I, QC I stated the expectation for pain reassessment documentation after oral pain medication administration is "at least after 2 hours," and confirmed the pain assessment and reassessments were not completed according to their policy.