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Based on record review and interview, the nursing staff failed to provide appropriate assessments by failing to document a focused nursing assessment in 1 of 10 emergency department (ED) patients (Patient #6) and failing to complete pain assessments in 1 of 6 ED patients presenting with pain (Patient #8) in a total of 10 medical records reviewed.

Findings include:

Record review of policy "Nursing Documentation" #23908 and Attachment A, effective date 11/16/2022 under Purpose revealed "to set forth the requirements for nursing documentation in the patient's legal electronic health record (EHR). Attachment A Nursing Assessment Standards by Patient Venue, under ED column titled Initial Selected Assessment revealed "Pertinent data based on clinical presentation of patient."

Patient #6's medical record was reviewed on 5/25/2023 at 11:20 AM revealed Patient #6 was a 71-year-old who presented from urgent care in an ambulance 4/20/2023 at 4:26 PM with shortness of breath and dizziness. Patient #6 was assessed by the physician and discharged home 4/20/2023 at 7:12 PM. There was no nursing assessment documented.

On 5/25/2023 at 11:20 AM interview with Clinical Informatics Specialist O, Clinical Informatics Specialist O confirmed the nursing assessment was "not documented" for Patient #6.

Record review of policy "Pain Management," #2575, effective date 5/17/2023, under Procedure revealed the nurse will "conduct a comprehensive pain assessment... when pain is present... or behaviors indicating pain."

Patient #8's medical record was reviewed on 5/25/2023 at 11:55 AM and revealed Patient #8 was a 33-year-old who presented to the ER on 5/07/2023 at 8:40 AM for evaluation of right shoulder pain. Patient #8 received a shot of Toradol (anti-inflammatory), shoulder x-ray was negative, and Patient #8 eloped 5/25/2023 at 10:22 AM. There was no nursing pain assessment documented.

On 5/25/2023 at 11:55 AM during interview with Clinical Informatics Specialist O, Clinical Informatics Specialist O confirmed documentation of the pain assessment was "not done" in Patient #8's medical record.

Based on record review and interview, the nursing team members failed to ensure documentation of intravenous (IV) assessments and removal of IV catheters in 3 of 7 patients who received intervenous catheter insertions (Patient #1, #9 & #10) in a total of 10 medical records reviewed.

Findings include:

Record review of policy "Nursing Documentation" #23908, effective date 11/16/2022 revealed "timely documentation of "all assessment parameters... which are planned by the registered nurse (RN) based on the patient's risk, symptoms and conditions, "is the responsibility of all nursing team members."

Record review of policy "Intravenous Therapy, Peripheral," #69812, effective date 6/08/2022, Table 1 "Peripheral Intravenous Catheter (PIVC) Device Protocols-Guidelines for Adults and Pediatrics" under column titled Important Information revealed "PIVC's are replaced when clinically indicated and with a thorough assessment by the clinician."

Record review of Ultrasound Guided IV Insertion Competency dated 10/03/2017 revealed "Document IV details in EHR" (electronic health record).

Patient #1's medical record revealed patient #1 was a 50-year-old who presented to the ED 4/06/2023 at 8:49 PM with abdominal pain. IV catheter was inserted after multiple attempts, using ultrasound. A computed tomography (CT) of the abdomen and pelvis was completed and Patient #1 left 4/06/2023 at 12:48 AM before receiving CT results or discharge instructions. There was no documentation of IV catheter site re-assessment or that the IV catheter was removed.
Patient #9's medical record revealed Patient #9 was a 86-year-old who presented to the ED 4/06/2023 at 8:19 AM with urinary retention problems. An IV catheter was inserted 9:18 AM. A urinalysis showed a urinary tract infection. A Foley catheter was placed obtaining 900 cc of urine out and Patient #9 was discharged 4/06/2023 at 11:27 AM. There was no documentation that the IV catheter was removed.

Patient #10's medical record revealed Patient #10 was a 37-year-old who presented to the ED 3/31/2023 at 2:06 AM with right flank pain. An IV catheter was inserted at 2:18 AM. CT of the abdomen and pelvis revealed a 2.5 millimeter stone at the right ureterovesicular junction. Patient # 10 was discharged 3/31/2023 at 4:31 AM. There was no documentation that the IV catheter was removed.

On 5/25/2023 during medical record review from 10:00 AM to 12:25 PM and interview with Clinical Informatics Specialist (CNS) O and RN House Supervisor N, CNS O confirmed there was "no documentation of removal" of Patient #1 and Patient #9's IV. House Supervisor N stated there should be documentation that the IV "was removed" in the medical record and confirmed, "I don't see" that documentation in Patient #10's medical record.