HospitalInspections.org

Based on staff interview, policy and procedure review and documentation in 2 of 6 medical records reviewed of emergency department (ED) patients with abdominal pain (#s 2 and 5), it was determined that the hospital failed to ensure the patients' pain was managed in accordance with appropriate assessment and its own policy.

Findings include:

1. The policy titled "Santiam Memorial Hospital Emergency Department Admission and Assessment and Reassessment," reviewed 05/2011 reflected "On admission or within four hours each patient will have documented a focused nursing assessment...Reassessment will be completed as often as indicated..." The policy included the following "Reassessment guidelines...
c. Reassessment at least every 30 minutes,
i. Patients with [abdominal] pain..."

2. The record of patient #5 revealed an "Admit Date/Time" of 07/05/2011 at 2305. The nurse's "Emergency Department Admission Form" dated 07/06/2011 at 0419 reflected the triage time was 2340 and chief complaint was abdominal pain. Further review reflected "Pain Scale 9...Onset Time 30 Mins Prior to Arrival to [ED]...Quality Sharp, Dull...Gastrointestinal Assessment...Upper [abdominal pain] Radiating to Back..." During an interview with the Director of Nursing on 01/05/2012 at 1530, he/she said the "pain scale" was based on a 1-10 scale and was used to assess the patient's pain.

The hospital form with the heading "Physician Assessment," date stamped 07/05/2011 revealed an IV was started in the patient's right antecubital at 0045, 65 minutes after the triage assessment. The "Medication" section of the form reflected
"GI cocktail 60cc p.o...refused...
Morphine Sulfate ['X' mark through 'Morphine Sulfate'] 4mg IV...refused...
Dilaudid 1-2mg ['X' mark through 'Dilaudid 1-2mg']...refused..."
The "Order Time" for all three medications was blank. The "Discharge To" and "Summary and Diagnosis" sections reflected the patient had gallstones, was discharged home on 07/06/2011 at 0220 and "[Abdominal] pain resolved." Although the record indicated the patient's pain "resolved," the record lacked documentation when the patient's abdominal pain was reassessed as directed by hospital policy.

The physician's "Santiam Memorial Hospital Emergency Department Report" dictated 07/06/2011 at 0225 and transcribed 07/08/2011 1635 reflected "The patient states [he/she] has had pain in the upper abdomen bilaterally with onset approximately one hour ago...The patient states that the pain has been steady and intermittently better and worse...Ultrasound shows 'loads of gallstones'...The patient's pain resolved before pain medications were given." Although the record reflected the patient's pain "resolved," the record lacked documentation when the patient's pain was reassessed as directed by hospital policy.

3. An interview was conducted on 01/05/2012 at 1530 with the Director or Nursing. These findings were reviewed and he/she acknowledged that the record lacked documentation that the patient's pain was assessed as directed by hospital policy.

4. The record of patient #2 revealed an "Admit Date/Time" of 10/03/2011 at 0804. The nurse's "Emergency Department Admission Form" dated 10/03/2011 at 0817 reflected the triage time was 0815, chief complaint was abdominal pain, and "Triage Category" was "Emergent..." Further review reflected "Pain Location [Abdomen, Back]...Pain Scale 9...Quality Sharp...Gastrointestinal Assessment...Flank Pain, Low [abdominal] Pain..."

The hospital form with the heading "Physician Assessment," date stamped 10/03/2011 reflected "Summary and Diagnosis...Diverticulitis-Improving," and revealed the patient was discharged on 10/03/2011 at 1015, 2 hours after the triage assessment. Although the record reflected the patient's condition was "improving," the record lacked documentation when the patient's abdominal pain was reassessed as directed by hospital policy.

The physician's "Santiam Memorial Hospital Emergency Department Report" dictated 10/03/2011 at 1002 and transcribed 10/03/2011 at 1128 reflected "The patient presents on 10/03/2011 with...persistent abdominal pain and discomfort in spite of treatment with antibiotics..." The physician exam reflected "There is generalized abdominal distention, tenderness noted throughout the lower abdominal region." The record reflected the patient received IV pain and anti-nausea medications to treat his/her condition, however the record lacked documentation that the patient's abdominal pain was reassessed as directed by the hospital policy.

Based on staff interview, policy and procedure review and documentation in 2 of 6 medical records reviewed of emergency department (ED) patients with abdominal pain (#s 2 and 5), it was determined that the hospital failed to ensure the patients' pain was managed in accordance with appropriate assessment and its own policy.

Findings include:

1. The policy titled "Santiam Memorial Hospital Emergency Department Admission and Assessment and Reassessment," reviewed 05/2011 reflected "On admission or within four hours each patient will have documented a focused nursing assessment...Reassessment will be completed as often as indicated..." The policy included the following "Reassessment guidelines...
c. Reassessment at least every 30 minutes,
i. Patients with [abdominal] pain..."

2. The record of patient #5 revealed an "Admit Date/Time" of 07/05/2011 at 2305. The nurse's "Emergency Department Admission Form" dated 07/06/2011 at 0419 reflected the triage time was 2340 and chief complaint was abdominal pain. Further review reflected "Pain Scale 9...Onset Time 30 Mins Prior to Arrival to [ED]...Quality Sharp, Dull...Gastrointestinal Assessment...Upper [abdominal pain] Radiating to Back..." During an interview with the Director of Nursing on 01/05/2012 at 1530, he/she said the "pain scale" was based on a 1-10 scale and was used to assess the patient's pain.

The hospital form with the heading "Physician Assessment," date stamped 07/05/2011 revealed an IV was started in the patient's right antecubital at 0045, 65 minutes after the triage assessment. The "Medication" section of the form reflected
"GI cocktail 60cc p.o...refused...
Morphine Sulfate ['X' mark through 'Morphine Sulfate'] 4mg IV...refused...
Dilaudid 1-2mg ['X' mark through 'Dilaudid 1-2mg']...refused..."
The "Order Time" for all three medications was blank. The "Discharge To" and "Summary and Diagnosis" sections reflected the patient had gallstones, was discharged home on 07/06/2011 at 0220 and "[Abdominal] pain resolved." Although the record indicated the patient's pain "resolved," the record lacked documentation when the patient's abdominal pain was reassessed as directed by hospital policy.

The physician's "Santiam Memorial Hospital Emergency Department Report" dictated 07/06/2011 at 0225 and transcribed 07/08/2011 1635 reflected "The patient states [he/she] has had pain in the upper abdomen bilaterally with onset approximately one hour ago...The patient states that the pain has been steady and intermittently better and worse...Ultrasound shows 'loads of gallstones'...The patient's pain resolved before pain medications were given." Although the record reflected the patient's pain "resolved," the record lacked documentation when the patient's pain was reassessed as directed by hospital policy.

3. An interview was conducted on 01/05/2012 at 1530 with the Director or Nursing. These findings were reviewed and he/she acknowledged that the record lacked documentation that the patient's pain was assessed as directed by hospital policy.

4. The record of patient #2 revealed an "Admit Date/Time" of 10/03/2011 at 0804. The nurse's "Emergency Department Admission Form" dated 10/03/2011 at 0817 reflected the triage time was 0815, chief complaint was abdominal pain, and "Triage Category" was "Emergent..." Further review reflected "Pain Location [Abdomen, Back]...Pain Scale 9...Quality Sharp...Gastrointestinal Assessment...Flank Pain, Low [abdominal] Pain..."

The hospital form with the heading "Physician Assessment," date stamped 10/03/2011 reflected "Summary and Diagnosis...Diverticulitis-Improving," and revealed the patient was discharged on 10/03/2011 at 1015, 2 hours after the triage assessment. Although the record reflected the patient's condition was "improving," the record lacked documentation when the patient's abdominal pain was reassessed as directed by hospital policy.

The physician's "Santiam Memorial Hospital Emergency Department Report" dictated 10/03/2011 at 1002 and transcribed 10/03/2011 at 1128 reflected "The patient presents on 10/03/2011 with...persistent abdominal pain and discomfort in spite of treatment with antibiotics..." The physician exam reflected "There is generalized abdominal distention, tenderness noted throughout the lower abdominal region." The record reflected the patient received IV pain and anti-nausea medications to treat his/her condition, however the record lacked documentation that the patient's abdominal pain was reassessed as directed by the hospital policy.