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Based on clinical record review, interview and policy review, the facility failed to document the reasons a patient with a Dilaudid allergy still received Dilaudid (Patient #5), and the facility failed to ensure employees followed its written policy for pain management for 5 of 25 sampled patients in its Emergency Department ((Patients #5, #1, #11,#19 and #20).

Findings include:

Patient #5

On 5/16/11, Patient #5 received treatment in the facility's emergency department with diagnoses of acute severe back pain, right hand radiculopathy, and secondary paresthesias.

1. In Patient #5's handwritten emergency department record, allergies included Dilaudid and Motrin. At 5:34 PM, Employee #14 administered 2 milligrams of intramuscular Dilaudid. The The entire emergency department record lacked documentation as to why Employee #14 administered the Dilaudid despite it being listed as an allergy.

On 9/7/11 at 3:30 PM, Employee #15 indicated a physician/nurse should document the reason for still administering a medication a patient has an allergy to.

On 9/8/11 at 9:45 AM, Employee #14 indicated "I missed it" when asked why Dilaudid was administered to Patient #5 with a documented allergy.

On 9/8/11 at 10:30 AM, Employee #16 indicated allergies are not always true allergies. For instance, if a patient was nauseous with a medication, Employee #16 would just add an anti-nausea medication and make a note regarding this. Employee #16 indicated he probably did not do that in this case.

On 9/8/11 at 1:30 PM, Employee #8 indicated a nurse should document a reason for administering a medication a patient was allergic to if still ordered to do so by a physician.

2. On 5/16/11 at 5:43 PM, Patient #5's location information record showed Patient #5 was in the WR area and at 8:25 PM Patient #5 was in ER13 (emergency area room 13).

On 9/8/11 in the morning, Employee #17 indicated he administered Percocet at 8:10 PM and took pain levels documented at 8:10 PM and 8:24 PM. He indicated WR meant the waiting room in the lobby.

The clinical record showed Patient #5's pain assessments at 4:41 PM, 8:10 PM, and 8:24 PM. At 5:34 PM, Patient #5 received intramuscular Dilaudid. The record lacked a nursing assessment of any kind between 4:41 PM and 8:10 PM.

On 9/8/11 at 8:45 AM, Employee #4 indicated Patient #5's clinical record lacked documentation for reassessing pain after the Dilaudid administration.

On 9/8/11 at 9:10 AM, Employee #5 indicated nurses were expected to document every two hours on patients.

On 9/8/11 at 10:30 AM, Employee #16 indicated patients were assigned to groups of nurses for monitoring and no one person was responsible for assessing.

On 9/8/11 at 1:30 PM, Employee #8 indicated the following: vital signs were documented every two hours. Nurses should monitor a patient's pain level an hour after an intramuscular administration of pain medication. According to nurse cluster assignments in the emergency department, no individual nurse was responsible for reassessing pain. Someone should have reassessed Patient #5's pain.


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The facility policy entitled Interdisciplinary Pain Management, effective 7/09, documented the clinician will accept the patient's report of pain and manage it appropriately.

The section entitled, Procedure:
3.1 "Pain is perceived differently by each individual. Therefore, the patient is the best person to assess the severity of pain. For those who can not assess their own pain, it will be assessed on their behalf by a healthcare professional using the patient's behavior and facial expressions."
5.1 Pain Assessment and Reassessment: "An assessment and reassessment will be performed and documented.
5.1.2 Pain reassessment occurs with every nursing assessment.
5.1.4 After every pain relieving intervention.
5.1.4.1 For adults, reassess patient within one (1) hour of intervention, comparing current pain intensity to acceptable pain intensity (goal) and evaluating for analgesic side effects.
6.0 Documentation
6.1 "All assessments, reassessments and interventions are documented in the patient's medical record."

Patient #1

Patient #1 arrived in the Emergency Department (ED) on 5/1/11 at 11:21 AM, and discharged 5/1/11 at 3:18 PM, with the chief complaint of severe back pain. The ED triage form documented Patient #1 was an adult and rated her pain at 9 according to the numeric rating scale (1-10). Her acceptable pain intensity was documented as 0.

On 5/1/11, physician's orders were received for Toradol 60 milligram (mg) and Valium 5 mg intramuscularly (IM). The Emergency Room (ER) treatment record documented the medications were both given at 11:56 AM. The ER treatment record documented Patient #1 received Dilaudid 1 mg IM at 12:26 PM.

Documentation entitled Depart Summary documented Patient #1 entered a waiting room at 12:41 PM and returned to an ED room at 2:12 PM.

The clinical record lacked documentation Patient #1 had been reassessed within one (1) hour of pain medication; the patient's current pain intensity was compared to acceptable pain intensity (goal), and the patient was evaluated for analgesic side effects. Documentation in the clinical record indicated Patient #1 had not been reassessed regarding her pain intensity level until 2:17 PM.

On 9/7/11 at 2:25 PM, Employee #6 verbalized a patient's pain level was assessed using the numeric pain scale (1-10) and patients were asked if their pain was at an acceptable level or not. Employee #6 stated a patient should be reassessed within 15 minutes after IV medication was given, and within 1 hour after the medication was given IM or orally.

On 9/7/11 at 2:30 PM, Employee #1 was not able to locate documentation in the clinical record to indicate Patient #1 had been reassessed for pain intensity in accordance with the facility's policy and procedure. Employee #1 verbalized the pain management policy and procedure was not followed.

On 9/8/11 at 9:10 AM, Employee # 5 stated a waiting room could be the waiting room by triage or E-19. The triage nurses should be monitoring patients in the front waiting area or E-19 and document in the clinical record. The expectation was nurses would chart on patients every 2 hours and document vital signs.

Patient #11

Patient #11 arrived in the ED on 8/11/11 at 10:53 AM, and discharged on 8/11/11 at 2:05 PM. Patient #11's chief complaint was right arm pain after "trip and fall while running with blanket." The ED triage form documented Patient #11 was a pediatric patient with a documented pain intensity of 8. The ED triage form lacked documentation of the patient's acceptable pain intensity level.

The ED Pediatric treatment Record contained an area on the form with the different faces to portray the pain level of the patient. According to the form, a pain intensity of 8 indicated "Hurts a Whole lot" with a sad face pictured.

The Emergency Note documented Patient #11 appeared to have some tenderness over the distal radius. Patient # 11 cried with any attempts to move any part. The x-ray of the right forearm showed a torus fracture of the distal radius, nondisplaced, with one single line of fracture that extended up to the growth plate. The patient was placed in a long-arm posterior splint and the patent was instructed to follow up with Pediatric Orthopedics.

The clinical record lacked documentation for Patient #11 a physician's order had been written or the patient was offered pain medication for a pain intensity level of 8.

On 9/7/11 at 2:35 PM, Employee #7 verbalized the standard of care for 2 year old child with a radial fracture included: vital signs, room the patient, take a medical history, a physical examination and order tests (i.e., x-ray). Employee #7 stated for pain the typical orders would be for Tylenol, Motrin or Morphine if the fracture was severe. Employee #7 stated he was not able to think of a situation when a fracture in a child would not hurt. Employee #7 verbalized if the mother or father refused pain medication for the child, staff would document the refusal in the medical record.

On 9/7/11 at 3:45 PM, Employee #2 reviewed the clinical record and was not able to determine why pain medication was not ordered/offered for a child with a fracture. Employee #2 verbalized a child with a radial fracture would have pain.

On 9/7/11 at 3:50 PM, Employee #1 reviewed the clinical record and was not able to locate documentation ice was applied, pain medications offered/given or pain medications had been refused. Employee # 1 confirmed the the pain management policy and procedure was not followed.

Patient #19

Patient #19 arrived in the ED at 12:28 AM and discharged at 3:50 AM. Patient #19's chief complaint was right upper quadrant abdominal pain. The ED triage form documented Patient #19 was an adult with a pain intensity of 8. The acceptable pain intensity was documented as 0.

On 6/1/11, a physician's order was received for Toradol 30 mg IVP and Dilaudid 1 mg, may repeat times two. The treatment record documented Dilaudid 1 mg was given IVP at 1:22 AM, and Toradol 30 mg IVP was given at 1:24 AM.

The clinical record lacked documentation Patient #19 had been reassessed within one (1) hour of pain medication; the patient's current pain intensity was compared to acceptable pain intensity, and the patient was evaluated for analgesic side effects. The clinical record documented Patient #19 was reassessed for pain intensity at 3:46 AM.

On 9/7/11, Employee #3 was not able to locate documentation Patient #19 had been reassessed within one (1) hour of pain medications and the patient's current pain intensity was compared to acceptable pain intensity. Employee #3 verbalized the policy and procedure for pain management had not been followed.

Patient #20

Patient #20 arrived in the ED on 6/1/11 at 3:29 PM, and discharged on 6/1/11 at 8:07 PM, with the chief complaint of pain across upper back/flank, radiating to front. The ED triage form documented Patient #20 was an adult and rated her pain at 8 according to the numeric rating scale. Her acceptable pain intensity was documented as 0.

On 6/1/11, a physician's order was given for Morphine 5 mg intravenous push (IVP) times 3 as needed (prn). The Morphine was administered at 4:06 PM, 5:00 PM and 6:25 PM.

The clinical record lacked documentation Patient #20 was reassessed within one (1) hour of pain medications, the patient's current pain intensity was compared to acceptable pain intensity and the patient was evaluated for analgesic side effects after receiving Morphine 3 times IVP. The clinical record indicated Patient #20 was not reassessed for pain intensity level until 8:03 PM.

On 9/8/11 at 8:36 AM, Employee #4 was asked if it was acceptable for a patient to sit in the waiting room for 2.5 hours with out being monitored. Employee #4 verbalized it depended upon the patient's diagnosis.

On 9/8/11 at 8:40 AM, Employee #3 was not able to locate documentation Patient #20 had been reassessed for pain intensity after the first dose of Morphine, before and after the second dose of Morphine and before and after the third dose of Morphine. Employee #3 was not able to locate documentation Patient #20 had been reassessed within one (1) hour of pain medications, the patient's current pain intensity was compared to acceptable pain intensity and the patient was evaluated for analgesic side effects after receiving Morphine 3 times IVP. Employee #3 verbalized the policy and procedure for pain management had not been followed.

Complaint #NV00028964

Based on clinical record review, interview and policy review, the facility failed to establish a policy governing its emergency department's physicians' use of prescription pads for 1 of 25 sampled patients (Patient #3) and 1 of 5 unsampled patients (Patient #30) and failed to follow its pain management policy regarding 1 of 25 sampled patients (Patient #11).

Findings include:

Patient #3

On 5/16/11, Patient #3 received treatment in the facility's emergency department for an acute back sprain following a motor vehicle accident.

On 5/16/11, Employee #12 wrote a discharge prescription for Motrin 800 milligrams by mouth every eight hours for two days, Lortab 7.5 milligrams by mouth every six hours as needed for severe pain, a work excuse for the next two days, and Tylenol with Codeine elixir ten milliliters by mouth every six hours as needed for pain. Employee #12 crossed out the prescription for Lortab but documented Patient #3 received it. Employee #12 signed each of the prescriptions but used Employee #13's DEA (Drug Enforcement Administration) number for the Motrin, Lortab, and work excuse.

On 9/8/11 at noon, Employee #12 indicated physicians usually did not stamp the prescriptions; the health unit clerks usually stamped them. Employee #12 acknowledged the signature as his on each of the four prescriptions.

When asked for the policy governing the use of prescription pads, Employee #11 indicated the hospital provided them as a courtesy for physicians who acted under their own licenses. Employee #12 indicated the hospital lacked a policy and referred to federal/state laws.

On 9/8/11 at 1:30 PM, Employee #8 indicated a pharmacist would not fill prescriptions without questioning who the doctor was. Prescriptions should be properly filled out with a physician's name, DEA number, patient name, and proper prescription.

Patient #30

On 5/16/11, the facility admitted Patient #11 with a diagnosis of nondisplaced fracture of the left mandible angle and left symphysis, status open reduction, internal fixation.

On 5/17/11, Employee #9 wrote a discharge prescription for Augmentin 875 milligrams by mouth twice daily, Roxanol 10-20 milligrams by mouth 4-6 hours as needed for two weeks, and Phenergan 12.5 milligrams by mouth every six hours as needed. Employee #9 failed to sign the prescription and provide a DEA number stamp on the prescription.

On 9/8/11 at noon, Employee #10 and #11 indicated Roxanol was not a narcotic.

On 9/8/11 at 1:00 PM, Employee #12 provided an information sheet, which indicated each milliliter of Roxanol contained 20 milligrams of Morphine Sulfate, and Morphine Sulfate acted as a narcotic analgesic.
Employee #12 indicated Roxanol was a class III narcotic, the DEA number should be on a prescription which included Roxanol, the prescription should be signed, and a pharmacist might call the physician and/or tell the patient to return to the physician to fill out the prescription properly, possibly causing a delay in treatment.

When asked for the policy governing the use of prescription pads, Employee #11 indicated the hospital provided them as a courtesy for physicians who acted under their own licenses. Employee #12 indicated the hospital lacked a policy and referred to federal/state laws.


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The facility policy entitled Interdisciplinary Pain Management, effective 7/09, documented the clinician will accept the patient's report of pain and manage it appropriately.

The section entitled, Procedure:
3.1 "Pain is perceived differently by each individual. Therefore, the patient is the best person to assess the severity of pain. For those who can not assess their own pain, it will be assessed on their behalf by a healthcare professional using the patient's behavior and facial expressions."
5.1 Pain Assessment and Reassessment: "An assessment and reassessment will be performed and documented.
5.1.2 Pain reassessment occurs with every nursing assessment.
5.1.4 After every pain relieving intervention.
6.0 Documentation
6.1 "All assessments, reassessments and interventions are documented in the patient's medical record."

Patient #11

Patient #11 arrived in the ED on 8/11/11 at 10:53 AM, and discharged on 8/11/11 at 2:05 PM. Patient #11's chief complaint was right arm pain after "trip and fall while running with blanket." The ED triage form documented Patient #11 was a pediatric patient with a documented pain intensity of 8. The ED triage form lacked documentation of the patient's acceptable pain intensity level.

The ED Pediatric Treatment Record contained an area on the form with the different faces to portray the pain level of the patient. According to the form, a pain intensity of 8 would indicated "Hurts a Whole lot" with a sad face pictured.

The Emergency Note documented Patient #11 appeared to have some tenderness over the distal radius. Patient #11 cried with any attempts to move any part. The x-ray of the right forearm showed a torus fracture of the distal radius, nondisplaced, with one single line of fracture that extended up to the growth plate. The patient was placed in a long-arm posterior splint and the patent was instructed to follow up with Pediatric Orthopedics.

The clinical record lacked documentation for Patient #11 a physician's order had been written or the patient was offered pain medication for a pain intensity level of 8.

On 9/7/11 at 2:35 PM, Employee #7 verbalized the standard of care for 2 year old child with a radial fracture included: vital signs, room the patient, take a medical history, a physical examination and order tests (i.e., x-ray). Employee #7 stated for pain the typical orders would be for Tylenol, Motrin or Morphine if the fracture was severe. Employee #7 stated he was not able to think of a situation when a fracture in a child would not hurt. Employee #7 verbalized if the mother or father refused pain medication for the child, staff would document the refusal in the medical record.

On 9/7/11 at 3:45 PM, Employee #2 reviewed the clinical record and was not able to determine why pain medication was not ordered/offered for a child with a fracture. Employee #2 verbalized a child with a radial fracture would have pain.

On 9/7/11 at 3:50 PM, Employee #1 reviewed the clinical record and was not able to locate documentation ice was applied, pain medications offered/given or pain medications had been refused. Employee #1 confirmed the the pain management policy and procedure was not followed.