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Based on documentation review the Hospital (Hospital #1) failed to implement and/or document further actions to improve informing patients of delays when the previous actions did not evidence sustained success.

Findings included:

Review of Hospital #1's Emergency Department (ED) Patient Satisfaction Survey data for 1/1/10 to 1/31/10 indicated that keeping patients informed of delays was the lowest scoring area of evaluation at 73.2%. Review of the score for 2/10 indicated that it improved slightly to 76.2% however; informing patients of delays was the second lowest score for the ED.

Review of the ED Staff Meeting Minutes, dated 3/26/09, 10/1/09, 12/3/09, 1/7/10, and 2/4/10 and the Management Council Meeting Minutes, dated 2/25/10, indicated that informing patients of delays was recognized as an ongoing area area in need of improvement.

Review of the actions implemented to address informing patients of delays in all Meeting Minutes were to make hourly rounding and/or to inform patients of delays.

Review of the Meeting Minutes indicated there was no evidence that the success of actions were evaluated and there was no evidence that additional actions were considered or implemented despite the ongoing concern for communication of delays.

Based on interviews and documentation review the Hospital (Hospital #1) failed to ensure that: 1). the Patient was medicated for pain in a timely manner in the Emergency Department and, 2). failed to reassess the effectiveness of pain medication on 2 occasions.

Findings included:

1). The Emergency Department (ED) Nursing Notes, dated 2/4/10, 9:07 A.M., indicated that the Patient was alert and oriented times three. The Patient rated the level of pain as a 9/10.

Review of Hospital #1's Policy/Procedure titled Pain Management indicated that the nurse was responsible for screening patients for the presence and intensity of pain and assessing the effectiveness of interventions. Presence and intensity of pain in the alert and oriented patient was screened by asking the patient to rate his/her pain using a scale that rated pain from 0 (no pain) to 10 (worst possible pain). The frequency of pain assessment/reassessment was based on the severity of the patient's pain as follows: pain rated as 0-4 was assessed at least every shift; pain rated as 4-6 was assessed at least every 4 hours, and pain rated as 6-10 if unchanged was reported to the physician. The effectiveness of pharmacological interventions was assessed 1-2 hours after administration of oral medication or 30-60 minutes after administration of intravenous medications. Documentation in the outpatient setting was entered into the nursing note.

The ED Record, dated 2/4/10 and timed 9:58 A.M., indicated that orders were written and included insertion of an intravenous line and intravenous Toradol (a nonsteroidal anti-inflammatory medication used for sort-term management of moderately severe acute pain). The Toradol order had a single line through it.

Review of the medical record and Pharmacy Activity Report determined that there were unsuccessful multiple attempts to insert an intravenous line and therefore the Toradol had not been administered.

The nurse who took over the Patient ' s care at 11:00 A.M. (ED Nurse #2) was interviewed on 3/2/10 at 7:15 A.M. ED Nurse #2 said an order was written for an alternative method of pain administration because there had been multiple unsuccessful attempts to insert an intravenous line.

The ED Record, dated 2/4/10, timed 11:50 A.M., indicated that an order was written for injectable Dilaudid (narcotic analgesic medication) to be administered.

The ED Nursing Notes, dated 2/4/10, 12:02 P.M., indicated that the Dilaudid was administered intramuscularly.

Physician Orders, dated 2/4/10, indicated that intravenous Dilaudid was ordered for pain management every 6 hours as needed.

Pain medication was not administered to the Patient with pain of 9/10 for almost 3 hours from the time the Patient arrived in the ED.


2). The Pain Assessment Screen, dated 2/7/10, indicated that at 4:30 A.M. the Patient rated the pain as 7/10 and was medicated with Dilaudid. Reassessment of the effectiveness of the medication was not documented.

The Pain Assessment Screen, dated 2/8/10, indicated that at 12:00 A.M. the Patient rated the pain as 7/10 and was medicated with Dilaudid. Reassessment of the effectiveness of the medication was not documented.

Based on interview and documentation review the Hospital (Hospital #1) failed to ensure that the practitioner documented insertion of an intravenous line.

Findings included:

The medical record documentation indicated that on 2/4/10 the Patient presented to the ED with a chief complaint of a stiff neck.

The ED Record, dated 2/4/10, indicated that orders were written for insertion of an intravenous line.

The nurse assigned to the Patient upon arrival to the ED (ED Nurse #1) was interviewed on 3/2/10 at 9:20 A.M. ED Nurse #1 reported attempting to insert an intravenous line and after 3 times was unsuccessful. ED Nurse #1 said 2 other staff members attempted to insert an intravenous line and were unsuccessful.

The ED Nursing Notes, dated 2/4/10, indicated that multiple attempts had been made to insert an intravenous line and a physician (identified as the Radiologist) attempted to insert an intravenous line using ultrasound (uses sound to outline the shapes of tissues and organs in the body) and was unsuccessful.

The ED Physician (ED Physician #1) was interviewed on 3/2/10 at 9:00 A.M. and throughout the survey. ED Physician #1 said he spoke with the Patient regarding insertion of a central line. ED Physician #1 said the Patient was hesitant but finally agreed. ED Physician #1 said as he was preparing the Patient for the line he noted the Patient had a good access at the jugular vein (located in the neck). ED Physician #1 said he explained to the Patient insertion of an intravenous line into the neck would be easier and less invasive. ED Physician #1 said the Patient agreed. ED Physician #1 said the intravenous was easily inserted into the jugular vein on the first try.

Review of the ED documentation indicated that although the time the intravenous line was inserted was documented, there was was no documentation to indicate who inserted the intravenous line, the type of line inserted, or the site of the insertion.