HospitalInspections.org

Based on record review, policy review and staff interview it was determined the facility failed to ensure care was documented in the Emergency Department (ED) records per policy and expectation for five (5) of fifteen (15) ED records reviewed (patients #1, 3, 6, 9 and 13). This failure creates the potential for an adverse impact on the care of all ED patients.

Findings include:

1. The Emergency Nursing Record for patient #1, completed by RN #1 at 11:24 on 9/22/14, was reviewed. The 'Pain Level' section of the triage assessment was not completed. The patient's blood pressure (BP) was noted as 165/100 at 11:24 a.m., 177/113 at 1:37 p.m. and 186/106 at 2:07 p.m. (higher than 130/80 is considered to be elevated).

The record reflected the patient reported his pain as seven (7) on a scale of zero (0) - ten (10) at both 1:37 p.m. and 2:07 p.m. The Emergency Physician Record for patient #1 reflects physician #1 examined the patient at 12:28 p.m. on 9/22/14 and noted the chief complaint as "coming off methadone, stomach pain."

Further review of the record revealed the patient was discharged home at 2:13 p.m. on 9/22/14. The record lacked any documentation to reflect the elevated BP was referred to the physician and/or addressed. The record lacked documentation to reflect the patient's pain level was addressed and/or discussed with the patient prior to discharge.

The above record was reviewed and discussed with RN #1 at 11:35 a.m. on 3/9/15. She confirmed she performed the triage and nursing assessment on patient #1. She also acknowledged the pain section was not completed at triage nor did the record contain documentation to reflect the elevated blood pressure readings were referred to the physician.

2. The Emergency Nursing Record for patient #3, completed by RN #3 at 2:52 p.m. on 1/31/15, was reviewed. The 'Pain Level' section of the triage assessment was not completed.

3. The Emergency Nursing Record for patient #6, completed by RN #4 on 1/29/15, was reviewed. The patient's BP was noted as 217/97 at 1:52 p.m., 188/95 at 2:02 p.m., 183/93 at 4:14 p.m. and 177/89 at 5:41 p.m. The record lacked documentation to reflect the elevated BP levels were referred to the physician.

4. The Emergency Nursing Record for patient #9, completed by RN # 5 on 1/21/15, revealed the patient was triaged at 2:57 p.m. The record reflects the patient's BP was not recorded until 4:35 p.m.

5. The Emergency Nursing Record for patient #13, completed by RN #5 on 1/21/15, was reviewed. The patient's BP was noted as 155/101 at 3:48 p.m. and 156/103 at 5:03 p.m. The patient was discharged at 6:10 p.m. with no documentation to reflect the elevated BP levels were referred to the physician or rechecked.

6. The records for patients #3, 6, 9 and 13 were reviewed and discussed with the ED Nurse Manager at 2:30 p.m. on 3/10/15 and she agreed with the findings.

7. The policy, "Pain Management, " effective date 2/14, was provided for review. The policy states in part: "The assessment of pain is an important part of the triage process. This provides a baseline for the patient's experience to help guide pain management during the Emergency Department visit. Patients will be assessed for pain using the appropriate pain scale."

8. The policy, "Triage," effective date 10/09, was provided for review. The policy states in part: "ED Nurse calls patient to triage area and performs assessment including name and age, chief complaint, vital signs, medications taken at home, allergies, medical history, name of primary care physician, physical assessment...The Triage nurse will make the Emergency Dept physician aware of all patients, their chief complaints and vital signs."