HospitalInspections.org

Based on record review and interview, the facility failed to ensure the nursing staff followed the facility policy regarding reassessment of emergency room patients. This includes failure to complete vital signs in three (3) (ID# 5,7,10) of 13 patient records reviewed and pain reassessment of nine (9) (ID#3,4,5,6,10,11,12,13) of 13 patient records reviewed.

Finding Include: Record review of the facility policy "Assessment and Reassessment-Patient Care Acuity Levels" last reviewed 08/2025 stated:
Vital signs (VS) are not a required component of the reassessment...should be performed prior to disposition.

v. Pain level should be reassessed 30 minutes after medication administration and documented in the EHR.

Patient (ID#3) received Toradol 15mg on 01/11/2023 at 2142 for leg pain, and was discharged at 0500 without a pain reassessment.

Patient (ID#4) received Toradol 30mg on 03/15/2023 at 0456 for back pain and testicular pain, he was discharged at 0500 without a pain reassessment.

Patient (ID#5) received Toradol 30mg on 03/15/15/23 at 1649, for abdomen pain, no pain reassessment was completed prior to discharge at 1800. No vital signs were documented prior to discharge

Patient (ID#6) received Toradol 15 mg at 1732 and Toradol 30 mg at 1825 on 03/15/2023 for abdominal pain and was discharged at 0702 without a pain reassessment.

Patient (ID#7) received Tylenol and Robitussin at 0723 and was discharged at at 0753 without a set of vital signs taken.

Patient (ID#10) received Balafon 20mg and Decadron 4mg, at 1621 and 1620 on 01/11/23, for hip pain at a level 10. Patient was discharged at 1720 without a pain reassessment. No vital signs were documented prior to discharge.

Patient (ID#11) received Tylenol 1000mg on 01/11/23 for a sprain and was discharged without a pain reassessment.

Patient (ID#12) received 1 tab of hydrocodone on 01/11/23 at 2047 for a left knee pain and was discharged without a pain reassessment.

Patient (ID#13) received Toradol 30mg on 08/23/21 at 2039 and was discharged without a pain reassessment. A return visit on 09/06/21 was given Toradol 30mg at 0826, no pain assessment was completed at discharge.

Based in observation and interview the facility did not have EMTALA signs posted conspicuously in the emergency department or in a place or places likely to be noticed by all individuals entering the emergency department.

Findings Include:

Observation on 03/15/2023 at 1020 during the tour of the ED with staff (ID#54, 63), it was noted that no EMTALA signs were in the waiting room, results pending room and ambulance bay area.

Interview during the tour at 1020 with staff (ID#54) who verified the signs were not present and the ED had been renovated and the signs had not been replaced.