HospitalInspections.org

Based on record review, policy review and staff interview, it was determined the facility failed to ensure polices regarding assessment and reassessment, discharge documentation and pain management were followed for 1 (#1) of 10 sampled patients.

Findings include:

Patient #1 was taken to the facilities Emergency Department (ED) on 12/4/13 at approximately 10:30 a.m. The chief complaint was left foot pain. Vital signs were recorded at that time and again at 11:59 a.m. There was no further documentation of vital signs. The last timed documentation was medication administration at 1:07 p.m. The time of discharge was not documented, but was after 1:07 p.m.

The facility policy "ED Vital Signs", # 3.780.006, revised 11/13, requires that vital signs be recorded at the time of discharge. There was no evidence that the facility complied with their policy.

The facility policy "Pain Management" # 2.600.154, revised 10/13, requires that pain intensity is to be measured using an age appropriate pain scale and that there is a reassessment within one hour of pain relief intervention. Review of triage documentation at 10:38 a.m. revealed that the intensity of the pain was not documented. The nurse documented that 5 milligrams of Morphine was administered at 11:25 a.m. There was no documentation of a pain assessment at that time. A pain assessment was documented at 11:55 a.m., noting the pain level to be 5 on a 0 - 10 scale. It could not be determined if the morphine had relieved the pain since there was no prior assessment. The nurse documented that oxycodone was administered at 1:07 p.m. There was no pain assessment documented at that time and no assessment following the administration of the pain medication. There was no documentation of the pain level at the time of discharge.

Review of the physicians medical screening examination revealed that the ambulance personnel had documented that patient #1's blood glucose was 328. At 11:00 a.m. a lab report revealed the blood glucose was 213. The ED physician documented that the patient had received a morning dose of insulin. The physician ordered 10 Units of regular insulin, which was administered at 1:07 p.m. Review of nursing documentation revealed there was no documentation of reassessment of the patient's blood glucose after the insulin was administered. The facility's policy "Assessment/Reassessment" #2.600.048, revised 9/13 requires that patients are to be reevaluated and plan of care revised prior to discharge from the ED. The reevaluation is to include recheck of any abnormal vital signs, any change in status and to determine there is no change in status from any previous evaluation. The nurse failed to reevaluate the blood glucose after the insulin was administered and before the patient was discharged.

Review of the medical record for patent #1 from another facility revealed that the patient arrived via ambulance on 12/4/13 at approximately 3:45 p.m. The patient reported his blood glucose to be below 30. One - half amp of 50% dextrose was administered in the ambulance. The blood glucose was found to be 38 in the ED. The patient required admission to the Intensive Care Unit.

The Clinical Nurse Coordinator or Progressive Care was present during the review of the medical record on 1/15/14 beginning at approximately 10:30 a.m. and confirmed the above findings, with the exception of documentation from the other facility.

The facility's policy "ED Discharge Process", no number, dated 10/13 requires the following information to be documented at the time of discharge: an assessment of the patient's ambulatory status, functional status, and ability to perform Activities of Daily Living; reassessment, including vital signs prior to discharge and correct disposition status Review of the medical record revealed there was no discharge disposition documentation in the record of patent #1. The Clinical Nurse Coordinator of the ED was interviewed on 1/15/14 at approximately 3:00 p.m. He confirmed that the nurse failed to document the discharge disposition as required. The patient had arrived via ambulance. The Clinical Nurse coordinator could not determine by what conveyance the patient was transported home.