HospitalInspections.org

Based on review of medical records (MR), review of documents, and interviews with staff (EMP) it was determined the facility: A) failed to correctly register a patient, MR4; B) failed to reassess pain as per facility policy for five (5) of six (6) patient encounters reviewed, MR4, MR8, MR10, who received pain medication; and C) failed to document vital signs for one (1) of ten (10) patients' medical records reviewed, MR4, as per facility policy.

Findings:

A) Review of facility document "Patient Identifiers" last revised May 2024 reads in part: "... Procedure: A. Identification Verification. 1. At the time the patient is registered and prior to the armband being applied, patient identification is established by asking the patient to state last, first, middle names, and date of birth. a. The stated names and date of birth are compared to a government issued photo identification (driver's license, DMV [department of motor vehicles] issued identification card, Passport etc.) when available for verification of identity.... 2. If two or more patients have the same first, middle, last name and date of birth, the social security number or government issued identification number may be used as a third identifier.... C. Initial application of the Armband ... 2. When a patient is brought directly to a department, bypassing the registration department, a member of the department staff applies the armband, after the patient states his/her full name and date of birth...."

Review of facility document "Patient Access Department: It is the policy of the Patient Access Department to adhere to EMTALA standards and state law when performing Emergency Department (ED) patient registration." approved May 1, 2024, reads in part: "... Procedure: Responsible Party - First Point of Contact: Greeter/Triage Nurse or Clinical/Nursing Staff. Action - Performs MPI search for prior patient information using the Patient's social security number, date of birth and sex. Staff recepts Patient into EDM module or Pre-Registers Patient into Meditech and completes First Point of Contact Screening...."

Review of the medical record for MR4 dated August 30, 2025, with EMP 6 revealed no documentation that the patient was registered incorrectly. EMP6 indicated that there would be no evidence that the patient was registered initially as another patient since the medical record had been corrected by the facility.

Interview on December 1, 2025, at 11:00 AM, EMP11 indicated that patients presenting to the emergency department are pre-registered by clinical staff who obtain the patient's social security number, last name, first name, and date of birth. The patient is shown their armband to confirm the identification information is correct.

Interview on December 1, 2025, at 12:08 PM, EMP6 indicated that MR4 was registered on August 30, 2025, under another patient's account with the same last name and same date of birth. EMP8 indicated that the clinical staff member that pre-registered the patient looked at the last name and the date of birth, then did not verbally confirm identification with the patient or have the patient review the information on the armband.

Interview on December 2, 2025, at 9:30 AM, EMP13 indicated that registration staff determined that MR4 was pre-registered incorrectly under another patient's name with the same last name and date of birth when the registration staff arrived in the patient's room to register the patient.

Interview on December 2, 2025, at 10:17 AM, EMP15 indicated that incorrect pre-registration of patients in the emergency department by the clinical staff is still a daily occurrence.
Interview on December 2, 2025, at 10:30 AM, EMP10 indicated that there should be an event report submitted for all incorrectly pre-registered patients, but not all are reported. EMP10 indicated that the staff member who identifies the incorrectly pre-registered patient should submit the event report.

Interview on December 2, 2025, at 11:04 AM, EMP1 indicated that if a patient is registered incorrectly, the staff members who identify the mistake should submit an event report.


B) Review of facility document "Pain Management - Adults and Pediatrics" last revised November 2024 reads in part: "Policy - Adults: ... 3. Reassessment of each pharmacological and non-pharmacological intervention should be documented within on hour. Reassessment should include: i. Effectiveness of intervention. ii. A comparison of pain level by the same scale used originally. iii. Additional interventions as indicated.... Policy - Pediatrics: ... 3. Assess for pain prior to dose. Reassess at 30 and 60 minutes and every 3-4 hours after administration...."

Review of the medical record for MR4 dated August 20, 2025, with EMP6 revealed MR4 was administered Toradol 30 mg at 12:40 AM for seven (7) out of ten (10) pain assessed at 12:40 AM. The next pain reassessment documentation was over four (4) hours later at 5:27 AM.

Review of the medical record for MR4 dated August 30, 2025, with EMP6 revealed MR4 was administered Morphine 1 mg at 7:08 PM and Toradol 15 mg at 7:09 PM for five (5) out of ten (10) pain assessed at 7:09 PM. There was no pain reassessment documented in the patient's medical record. EMP6 indicated that there should have been a reassessment of pain after the medication was administered.

Review of the medical record for MR4 dated September 5, 2025, with EMP6 revealed MR4 was administered Toradol 15 mg at 5:52 PM for ten (10) out of ten (10) pain assessed at 5:52 PM. The next pain reassessment documentation was five (5) hours later at 10:52 PM.

Review of the medical record for MR8 dated September 1, 2025, with EMP6 revealed MR8 was administered ibuprofen 100 mg at 9:17 PM for seven (7) out of ten (10) pain assessed at 9:17 PM. There was no pain reassessment documented in the patient's medical record.

Review of the medical record for MR10 dated September 20, 2025, with EMP6 revealed MR10 was administered Morphine 4 mg at 3:28 PM for pain assessed as "Yes" in the nursing documentation. There was no pain reassessment documented in the patient's medical record.

Interview on December 1, 2025, at 11:18 AM, EMP6 indicated that nurses must reassess pain after administering medication within thirty to sixty minutes, as per policy.

Interview on December 1, 2025, at 2:48 PM, EMP12 indicated that depending on the pain medication, the patient's pain level should be reassessed within fifteen (15) minutes to one (1) hour.

Interview on December 2, 2025, at 9:30 AM, EMP13 indicated that the patient's pain should be reassessed and documented thirty (30) minutes to one (1) hour after a pain medication is administered.

Interview on December 2, 2025, in the morning, EMP5 confirmed that the facility's policy indicates that pain for a pediatric patient should be reassessed at 30 minutes and 60 minutes and every 3-4 hours after administration.


C) Review of facility document "ED Assessment and Reassessment Standards" not dated reads in part: "... Level 3: Urgent ... Vital signs and focused reassessment requirements ... Minimum every 2 hours and as condition warrants ..."

Review of the medical record for MR4 dated September 5, 2025, with EMP6 revealed MR4 was triaged as a Level 3 Urgent. EMP6 confirmed that MR4 had vital signs documented at 6:20 PM and the next set of vitals signs were documented at 3:53 AM, over eight (8) hours later. EMP6 indicated that the patient should have had more vital signs documented between 6:20 PM and 3:53 AM. EMP6 was unable to determine if the patient was being monitored during that time based on the documentation in the medical record.

Interview on December 2, 2025, at 11:44 AM, EMP5 indicated that a patient triaged at a level 3 should have vital signs documented at a minimum of every two (2) hours as per the facility's ED (emergency department) Assessment and Reassessment procedure.