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Tag No.: A0118
Based on record review and interview the facility failed to respond to (2) out of (6) patient's requests for reasonable care and services when Patient #1 was discharged twice with severe pain; and Patient # 3 was discharged twice with an elevated blood pressure.
Findings Include:
Review of the facility provided document Pain Management (dated 9/22/14) reflected:
"Purpose:
The purpose of the pain management plan is to ensure the patient has optimal comfort through a proactive interdisciplinary team approach ...The patient's report of pain will be accepted as the key indicator of the amount of pain experienced ....Pain will be evaluated and managed utilizing the Pain AIR Cycle Framework. The framework consists of 3 evaluating factors: Assessment, Intervention, and Reassessment (AIR). The Pain AIR Cycle focuses on treating a patient's established comfort goal. Upon initial assessment a comfort goal between 0/10 will be established with the patient ....Within an hour of the intervention, pain must be reassessed and documented. If the patient's pain remains above the comfort goal another intervention must occur ..."
Patient #1
Review of Patient #1's Emergency Department (ED) Triage Notes reflected: on 11/12/15 at 6:58 p.m., a 41 year old male arrived at the ED with a history of Hypertension, Migraine Headaches, Urinary Retention, and Back Pain status post injury several months ago. Past surgical history of right leg skin graft. Currently on Topamax for nerve pain management.
Further review of Patient #1's Triage note reflected: "Chief Complaint: Back pain .... The patient complains of right lower back pain that radiates down the right leg. Incident occurred 3 days ago ....pain as 7/10. The pain is described as shooting ..."
Review of the Nursing Notes dated 11/12/15 at 7:48 p.m. reflected pain medications were administered; Hydromorphone HCL Intramuscular 2 mg (milligrams); there was no pain level recorded prior to the administration or after the administration to determine effectiveness. There was no comfort goal written.
Triage Note on 11/14/15 at 11:34 a.m. reflected Patient #1 arrived at the ER "... Triage note; "Chief Complaint: Back Pain ...Patient was seen by clinic PTA (prior to arrival) ...collapsed in parking lot, states 'legs gave out on him.'" Patient c/o numbness to pelvis and right now ...pain as 10/10 ..."
Review of the Physician's notes at 12:48 p.m. reflected: "...He states that he was in an accident in April and that his pain has worsened since that time. He was seen here in the ED on 11/12 and was seen at his PCP (primary care provider) this morning and given a 'tramadol shot' with no relief. Associated symptoms: (+) numbness, (+) difficulty walking. (+) falling ..."
Review of the Nursing notes dated 11/14/15 at 12:43 p.m. reflected pain medications were administered, Ketorolac Intramuscular 60 mg. There was no pain level recorded prior to the administration or after the administration to determine effectiveness. There was no comfort goal written.
At 2:10 p.m. "attempted to discharge patient, requesting ERMD (Emergency Room Medical Doctor), ERMD refused to speak to patient again. House supervisor notified. Patient requesting narcotics. Patient is already prescribed and has a primary doctor who he saw this morning."
At 2:52 p.m. review of Patient #1's vital signs reflected: "...patient reported pain level of 10." Patient #1 was discharged from the Emergency Room at 2:53 p.m. with no additional pain intervention.
During an interview on 6/14/16 at 11:00 a.m. Staff #1, Risk Manager stated, "Patient #1's mother filed a complaint with the hospital concerning Patient #1's treatment. The Quality Management department initiated an investigation. We conducted a Root Cause Analysis (RCA); the Executive Director of Quality Management, the Emergency Department (ED) Section Chief, Director and Clinical Manager, the Police Chief and ED Charge Nurse participated in the RCA ....We determined the current ED practices were not sufficient for staff to advocate for their patients ....All the ED staff were re-educated on the appropriate de-escalation and chain of command processes. The ED Section Chief will be notified prior to Security being notified."
During an interview on 6/14/16 at 2:00 p.m. in the facility's Risk Managers office, Staff #2, Director of Emergency Department (ED) stated, "We educated all the ED staff using email and Facebook."
Review of the Educational Email (undated) content sent out to the ED staff reflected: "Basically, if the patient is requesting to see the doc, and the doc won't go back in to talk to them/deal with the issue, we are to call Staff #3, Medical Director, MD and inform him so he can handle the situation and try to de-escalate the issue. This stems from the guy with back pain refusing to leave and we called security on him, came back with spinal fractures and major complications. If they cannot get ahold of Staff #3, call me and I will send it up the chain if the provider is still refusing to try and resolve the situation. We also need to be careful on involving MPD/MMHPD (Police Department) if the patient has a reasonable request to see their treating physician, even if they have been discharged ....100% nursing staff educated on process by Feb. 15th."
Review of the facility provided document Patient's Rights (dated 2/24/2014) reflected:
"...You have the right to ...
· Receive kind, respectful, safe, quality care...
· Receive proper assessment and management of pain...
· Receive efficient and quality care with high professional standards ..."
Patient #3
Review of Patient # 3's Emergency Room Triage Note reflected: on 2/3/16 at 8:12 p.m. a 55 year old female weighing 130 lbs.(pounds) was admitted to the ED with a "Chief Complaint: Hypertension (HTN) ... Vital signs 8:14 p.m., 180 /115. In general, around 120/80 (120 systolic and 80 diastolic) is considered normal."
Review of Medication Administered reflected Patient #3 was administered Clonidine 0.2 mg (milligram) (medication used to lower Blood Pressure) by mouth.
Review of Patient #3's Physician's Notes written on 2/3/16 at 9:04 p.m. reflected "The patient presents with a complaint of Hypertension (HTN). The onset is unknown. The symptoms have been constant. The symptom severity is moderate. Context/precipitation: Pt states she is having syncopal episodes x2 due to HTN. Pt states she remembers standing and 'nothing after' ....Pt states hx (history) of sz (seizures), but states syncopal episodes are not seizures ...."
Review of Patient #3's discharge vital signs on 2/3/16 at "12:03 a.m. ...Vital Signs 164/111.
Review of Patient #3's Nursing Notes on 2/3/16 at 12:17 a.m., reflected "Disposition is discharged ...Patient was discharged to home ..."
Review of Patient #3's Triage Note dated 2/5/16 at 12:08 p.m. reflected Patient #3's; "Chief Complaint: Hypertension ...Vital Signs 204/102 ....Complains of history of hypertension ...The patient is taking their medications as prescribed ...patient reports increased urination verbalized her symptoms have been going on since last Wednesday ..."
Review of Patient #3's Physician's Notes dated 2/5/16 at 1:27 p.m. reflected "...The symptoms have been occurring for 9 days .... (+) increased urination, (+) hypertension, (+) CP (chest pain), (+) shaky ...risk factors: (+) hypertension, Hx of seizures, sleep apnea, TIA (transient ischemic attack) and asthma ... ...Pt states that she checked her blood pressure and that it has been high since her last ED visit. Pt also complains of feeling shaky and having a tightness in her chest ....Pt has a long list of antihypertensive medication.... has an appointment with (primary doctor) ... later today and pt will be discharged to attend the appointment."
Review of Patient#3's last set of vitals at 1:39 p.m. reflected "Vital Signs 184/116."
Review of Patient #3's Nurse's notes dated 2/5/16 at 2:01 p.m. reflected "Disposition is discharged ...Patient was discharged to home ...Vital signs within normal limits..." The record did not reflect what the patient's normal vital signs were.
Review of Patient #3's treatments for the 2/5/16 visit to the ED revealed there were no treatments or interventions ordered. Patient #3's blood pressure remained elevated and did not reflect the resolution of the chest tightness prior to discharging from the facility.
Review of Patient #3's Triage notes dated 2/5/16 at 3:30 p.m. reflected Patient #3 was transported to the emergency room by an ambulance. "Chief Complaint: Hypertension ...EMS (emergency medical services) reported the Blood Pressure at 217/115 .... At 3:38 p.m. Vital signs 189/127."
Review of Physician's Notes dated 2/5/16 at 3:41 p.m. reflected; " ... (+) SOB (shortness of breath), (+) CP (chest pain) ... risk factors: (+) hypertension, Hx [sic] of asthma, seizures, sleep apnea, and TIA (transient ischemic attack) ... ...Pt states she has not taken any of her medication today. Pt was seen earlier here in the ED for the past chief complaint and was discharged so she could attend her appointment. Pt states she became short of breath as she was walking from the ED to the ... Clinic."
Review of Patient 3's medical records dated 2/5/16 at 5:01 p.m. reflected; "CRITICAL CARE INDICATION: Patient was critically ill with a high probability of imminent or life threatening deterioration."
During an interview on 6/14/16 at 11:00 a.m. Staff #1, Risk Manager stated, "We didn't want to lower Patient #3's blood pressure too low ....Some people live with a higher blood pressure." When asked if a Root Cause Analysis had been conducted on Patient #3's repeated ED visits with elevated blood pressures and subsequent Critical Care admission, Staff #1 stated, "No."
Tag No.: A0273
Based on record review and interview the facility failed to review the effectiveness and safety of services and quality of care provided in the facility's Emergency departments when Patient #3 presented and was discharged from the ED with an elevated blood pressure.
Findings include:
Review of Patient # 3's Emergency Room Triage Note reflected: on 2/3/16 at 8:12 p.m. a 55 year old female weighing 130 lbs.(pounds) was admitted to the ED with a "Chief Complaint: Hypertension (HTN) ... Vital signs 8:14 p.m., 180 /115. In general, around 120/80 (120 systolic and 80 diastolic) is considered normal."
Review of Medication Administered reflected Patient #3 was administered Clonidine 0.2 mg (milligram) (medication used to lower Blood Pressure) by mouth.
Review of Patient #3's Physician's Notes written on 2/3/16 at 9:04 p.m. reflected "The patient presents with a complaint of Hypertension (HTN). The onset is unknown. The symptoms have been constant. The symptom severity is moderate. Context/precipitation: Pt states she is having syncopal episodes x2 due to HTN. Pt states she remembers standing and 'nothing after' ....Pt states hx (history) of sz (seizures), but states syncopal episodes are not seizures ...."
Review of Patient #3's discharge vital signs on 2/3/16 at "12:03 a.m. ...Vital Signs 164/111.
Review of Patient #3's Nursing Notes on 2/3/16 at 12:17 a.m., reflected "Disposition is discharged ...Patient was discharged to home ..."
Review of Patient #3's Triage Note dated 2/5/16 at 12:08 p.m. reflected Patient #3's; "Chief Complaint: Hypertension ...Vital Signs 204/102 ....Complains of history of hypertension ...The patient is taking their medications as prescribed ...patient reports increased urination verbalized her symptoms have been going on since last Wednesday ..."
Review of Patient #3's Physician's Notes dated 2/5/16 at 1:27 p.m. reflected "...The symptoms have been occurring for 9 days .... (+) increased urination, (+) hypertension, (+) CP (chest pain), (+) shaky ...risk factors: (+) hypertension, Hx of seizures, sleep apnea, TIA (transient ischemic attack) and asthma ... ...Pt states that she checked her blood pressure and that it has been high since her last ED visit. Pt also complains of feeling shaky and having a tightness in her chest ....Pt has a long list of antihypertensive medication.... has an appointment with (primary doctor) ... later today and pt will be discharged to attend the appointment."
Review of Patient#3's last set of vitals at 1:39 p.m. reflected "Vital Signs 184/116."
Review of Patient #3's Nurse's notes dated 2/5/16 at 2:01 p.m. reflected "Disposition is discharged ...Patient was discharged to home ...Vital signs within normal limits..." The record did not reflect what the patient's normal vital signs were.
Review of Patient #3's treatments for the 2/5/16 visit to the ED revealed there were no treatments or interventions ordered. Patient #3's blood pressure remained elevated and did not reflect the resolution of the chest tightness prior to discharging from the facility.
Review of Patient #3's Triage notes dated 2/5/16 at 3:30 p.m. reflected Patient #3 was transported to the emergency room by an ambulance. "Chief Complaint: Hypertension ...EMS (emergency medical services) reported the Blood Pressure at 217/115 .... At 3:38 p.m. Vital signs 189/127."
Review of Physician's Notes dated 2/5/16 at 3:41 p.m. reflected; " ... (+) SOB (shortness of breath), (+) CP (chest pain) ... risk factors: (+) hypertension, Hx [sic] of asthma, seizures, sleep apnea, and TIA (transient ischemic attack) ... ...Pt states she has not taken any of her medication today. Pt was seen earlier here in the ED for the past chief complaint and was discharged so she could attend her appointment. Pt states she became short of breath as she was walking from the ED to the ... Clinic."
Review of Patient 3's medical records dated 2/5/16 at 5:01 p.m. reflected; "CRITICAL CARE INDICATION: Patient was critically ill with a high probability of imminent or life threatening deterioration."
During an interview on 6/14/16 at 11:00 a.m. Staff #1, Risk Manager stated, "We didn't want to lower Patient #3's blood pressure too low ....Some people live with a higher blood pressure." When asked if a Root Cause Analysis had been conducted on Patient #3's repeated ED visits with elevated blood pressures and subsequent Critical Care admission, Staff #1 stated, "No."
Tag No.: A0449
Based on record review and interview the facility failed to enforce Patient #1's right to considerate and respectful care when Patient #1's requests to see the physician regarding pain management was ignored.
Findings include:
Review of the facility provided document Pain Management (dated 9/22/14) reflected:
"Purpose:
The purpose of the pain management plan is to ensure the patient has optimal comfort through a proactive interdisciplinary team approach ...The patient's report of pain will be accepted as the key indicator of the amount of pain experienced ....Pain will be evaluated and managed utilizing the Pain AIR Cycle Framework. The framework consists of 3 evaluating factors: Assessment, Intervention, and Reassessment (AIR). The Pain AIR Cycle focuses on treating a patient's established comfort goal. Upon initial assessment a comfort goal between 0/10 will be established with the patient ....Within an hour of the intervention, pain must be reassessed and documented. If the patient's pain remains above the comfort goal another intervention must occur ..."
Review of Patient #1's Emergency Department (ED) Triage Notes reflected on 11/12/15 at 6:58 p.m., a 41 year old male arrived at the ED with a history of Hypertension, Migraine Headaches, Urinary Retention, and Back Pain status post injury several months ago. Past surgical history of right leg skin graft. Currently on Topamax for nerve pain management.
Further review of Patient #1's Triage note reflected, "Chief Complaint: Back pain .... The patient complains of right lower back pain that radiates down the right leg. Incident occurred 3 days ago ....pain as 7/10. The pain is described as shooting ..."
Review of the Nursing Notes dated 11/12/15 at 7:48 p.m. reflected Hydromorphone HCL Intramuscular 2 mg (milligrams) [a pain medication]was given; there was no pain level recorded prior to the administration or after the administration to determine effectiveness. There was no comfort goal written.
Triage Note on 11/14/15 at 11:34 a.m. reflected Patient #1 arrived at the ER "... Triage note ...Chief Complaint: Back Pain ...Patient was seen by clinic PTA (prior to arrival) ...collapsed in parking lot, states 'legs gave out on him.' Patient c/o numbness to pelvis and right now ...pain as 10/10 ..."
Review of the Physician's notes at 12:48 p.m. reflected: "...He states that he was in an accident in April and that his pain has worsened since that time. He was seen here in the ED on 11/12 and was seen at his PCP (primary care provider) this morning and given a 'tramadol shot' with no relief. Associated symptoms: (+) numbness, (+) difficulty walking. (+) falling ..."
Review of the Nursing notes dated 11/14/15 at 12:43 p.m. reflected pain medications were administered, Ketorolac Intramuscular 60 mg. There was no pain level recorded prior to the administration or after the administration to determine effectiveness. There was no comfort goal written.
At 2:10 p.m. "attempted to discharge patient, requesting ERMD (Emergency Room Medical Doctor), ERMD refused to speak to patient again. House supervisor notified. Patient requesting narcotics. Patient is already prescribed and has a primary doctor who he saw this morning."
At 2:52 p.m. review of Patient #1's vital signs reflected "...patient reported pain level of 10." Patient #1 was discharged from the Emergency Room at 2:53 p.m. with no additional pain intervention.