HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to ensure to comply with the 24 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases. These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. The hospital failed to ensure the necessary stabilizing treatment was provided within the capabilities of the hospital provided for nine of 20 sampled patients (Patients 1, 4, 5, 7, 8, 9, 16, 19, and 20). Cross reference to A2407.

2. The hospital failed to ensure the ED staff completed the Psychiatric Patient Transfer Acknowledgment and Consent form when transferring one of 20 sampled patients (Patient 12) to other facility. Cross reference to A2409.

Based on observation, interview, and record review, the hospital failed to ensure the necessary stabilizing treatments were provided within the capabilities of the hospital for nine of 20 sampled patients (Patients 1, 4, 5, 7, 8, 9, 16, 19, and 20) as evidenced by:

1. The ED staff did not ensure the pain management for Patients 4, 16, 19, and 20 as per the hospital's P&P.

2. The ED staff did not conduct the reassessments including the vital signs every four hours for Patients 1, 5, 8, and 9 as per the hospital's P&P.

3. The ED staff did not assess the vital signs every two hours for Patient 7.

4. The ED staff did not check the crash cart on the 1/23 and 1/28/24 day shifts and 1/26/24 night shift as per the hospital's P&P.

These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. Review of the hospital's P&P titled Pain Management dated 9/8/23, showed Numerical Rating Scale (NRS) is one of the pain scales approved for use in the hospital. NRS is a numeric pain assessment tool in which patients are asked to verbally rate their current pain intensity on a scale of zero to 10 with zero being in no pain and 10 being the worst possible pain. All patients will be screened for the presence or absence of pain upon admission or initial contact in the ambulatory care setting utilizing one of the above-mentioned pain scales.

Review of the hospital's Nursing Clinical Standard titled Pain Management dated October 2023 showed assessment includes the following:

* Assess/reassess pain intensity/score a minimum of every four hours (acute care units).

* Assess/reassess pain characteristics as follows:

- Baseline assessment (upon first complaint of pain/complaint of new type of pain): location, laterality, quality, and time pattern.

* Reassess pain level less than one hour after intervention or as clinically indicated.

a. Review of Patient 16's closed medical record was initiated on 1/30/24.

Patient 16's medical record showed Patient 16 arrived in the ED on 10/2/23 at 1616 hours.

Review of the ED Triage Form dated 10/2/23 at 1619 hours, showed Patient 16 had the right sided chest pain radiating to the back. Patient 16's pain level was six out of 10.

Review of the Pain showed on 10/2/23 at 1638 hours, the Patient 16's primary pain location was on the chest. Patient 16's pain level was 10 out of 10. However, further review of the pain assessment documentation failed to describe the quality and time pattern as per the hospital's Nursing Clinical Standard.

Review of the Medication Administration Record showed on 10/2/23 at 1658 hours, Patient 16 was administered with hydromorphone (an opioid pain medication) 0.5 mg IVP.

Review of the Pain showed Patient 16's pain level was zero out of 10 on 10/2/23 at 1916 hours (or approximately two hours and 18 minutes later).

Further review of Patient 16's medical record failed to show documented evidence of reassessing the patient's pain within one hour, after administering hydromorphone as per the hospital's Nursing Clinical Standard.

On 1/30/24 at 1331 hours, the above findings were shared and verified with Nurse Manager 2 and Interim Clinical Nursing Director 1.

b. Review of Patient 19's closed medical record was initiated on 1/30/24.

Patient 19's medical record showed Patient 19 arrived in the ED on 12/13/23 at 1841 hours.

Review of the ED Trauma Triage dated 12/13/23 at 1847 hours, showed Patient 19 had pain on the left back. Patient 19's pain level was eight out of 10. However, the assessment was missing the pain quality and time pattern.

Review of the Assessment dated 12/13/24 at 1930 hours, showed Patient 19 had throbbing pain in the left abdomen. However, there was no documented evidence to show the patient's pain level was assessed.

Review of the Medication Administration Record showed on 12/13/23 at 2046 hours, showed Patient 19 received acetaminophen (pain medication) 1000 mg by mouth.

Review of the Discharge Documentation showed Patient 19 was discharged from the ED on 12/13/24 at 2118 hours.

However, further review of Patient 19's medical record failed to show Patient 19 was reassessed for pain after acetaminiphen was administered to the patient.

On 1/30/24 at 1331 hours, the above findings were shared and verified with Nurse Manager 2 and Interim Clinical Nursing Director 1.

c. Review of Patient 20's closed medical record was initiated on 1/30/24.

Patient 20's medical record showed Patient 20 arrived in the ED on 1/2/24 at 0218 hours.

Review of the ED Triage Form dated 1/2/24 at 0220 hours, showed Patient 20's pain level was eight out of 10. However, there was no documented evidence showing the pain location, quality, or time pattern was assessed for the patient as per the hospital's Nursing Clinical Standard.

Review of the Pain showed the following:

* On 1/2/24 at 0244 hours, Patient 20 had pain in the head. The patient's pain level was a nine out of 10. However, there was no documented evidence showing the pain quality or time pattern was assessed for the patient as per the hospital's Nursing Clinical Standard.

* On 1/2/24 at 0413 hours, Patient 20 had intermittent cramping in the suprapubic area with the pain level of eight out of 10.

Further review of the medical record failed to show Patient 20 received non-pharmacological or pharmacological pain interventions until 1/2/24 at 0640 hours.

Review of the Medication Administration Record showed on 1/2/24 at 0640 hours, Patient 20 received ibuprofen (a pain medication) 400 mg by mouth.

On 1/30/24 at 1331 hours, an interview and concurrent review of Patients 16, 19, and 20 was conducted with Nurse Manager 2. When asked what the expectation of pain assessment, reassessments, and intervention were for the patients in the ED, Nurse Manager 2 stated if a patient had a pain which needed to be addressed, the RN should contact the provider, provide treatment as ordered, and follow the hospital's P&P. The RN should assess the patient's pain completely, document the assessment, notify the provider, administer treatment, and reassess as per the hospital's P&P and the provider's order.

On 1/30/24 at 1331 hours, the above findings were shared and verified with Nurse Manager 2 and Interim Clinical Nursing Director 1.


35310


d. Patient 4's medical record was reviewed with Nurse Manager 2 on 1/30/24 at 1205 hours.

Patient 4's medical record showed Patient 4 arrived at the ED on 12/24/23 at 1032 hours.

Review of the ED Triage Form dated 12/24/23 at 1032 hours, showed Patient 4 had pain with the pain level of 10 out of 10.

Review of the ED Vital Signs and Pain dated 12/24/23 at 1054 hours, showed Patient 4 reported pain to his head. The patient's pain level was eight out of 10. However, further review of Patient 4's medical record failed to show the baseline pain assessment, including laterality, quality, and time pattern was completed for Patient 4 as per the hospital's Nursing Clinical Standard.

Review of the ED Note-Assessment dated 12/24/23 at 1306 hours, showed Patient 4 refused to be assessed. However, there was no documentation of pain management provided to the patient between 1054 hours and 1306 hours.

When asked, Nurse Manager 2 stated the intake nurse performed quick assessment including pain assessment and categorized a patient's ESI level. The next pain assessment should have included the baseline assessment. Nurse Manager 2 verified the above findings.

2. Review of the hospital's P&P titled Triage-Nursing Role Responsibilities dated September 2021 showed the following:

* The triage nursing team consists of a router, secondary assessment nurses, reassessment nurses, and ambulance triage nurses.

* Router nurse will determine level of severity using the Emergency Severity Index (ESI), based on clinical presentation and chief complaint and complete the triage form in the EHR. Patients who have an ESI level 2 or greater will be taken to an available bed or to the North Lean Track (NLT).

* Room 2/Adult Waiting Reassessment Nurse will provide limited diagnostic studies and treatment as ordered. Patients categorized as acuity 3 (ESI level 3) will be reassessed, including vital signs a minimum of every four hours.

a. Patient 1's medical record was reviewed with Nurse Manager 4 on 1/29/24 at 1037 hours.

Patient 1's medical record showed Patient 1 arrived at the ED on 1/8/24 at 1328 hours.

Review of the ED Triage Form dated 1/8/24 at 1330 hours, showed Patient 1 was triaged with the acuity level "3".

Review of the Medical Screening Exam dated 1/8/24 at 1346 hours, showed Patient 1's tracking acuity was "3."

Review of the ED Vital Signs and Pain dated 1/8/24 at 1421 hours, showed Patient 1's vital signs were measured.

Review of the ED Note-Assessment dated 1/8/24, showed Patient 1's reassessment including the vital signs was performed at 2141 hours (or seven hours and 20 minutes later).

When asked, Nurse Manager 4 stated patient whose acuity level was categorized as three, should be assessed every four hours, including the vital signs. Nurse Manager 4 stated Patient 1 should have been reassessed by 1821 hours, including the vital signs. Nurse Manager 4 verified the above findings.

b. Patient 5's medical record was reviewed with Nurse Manager 2 on 1/30/24 at 1205 hours.

Patient 5's medical record showed Patient 5 arrived at the ED on 1/2/24 at 1055 hours.

Review of the ED Triage Form dated 1/2/24 at 1056 hours, showed Patient 5's vital signs were taken. The patient was triaged with the acuity level "3."

Review of the Medical Screening Exam dated 1/2/24 at 1123 hours, showed Patient 5's tracking acuity was "3".

However, review of the ED Notes dated 1/2/24 at 1918 hours, showed Patient 5 did not answer call.

There was no documentation showing the nursing staff had encountered Patient 5 until 1/2/24 at 1918 hours (or eight hours and 22 minutes later).

When asked, Nurse Manager 2 stated Patient 5's assessment including the vital signs should have been performed by 1523 hours. Nurse Manager 2 verified the above findings.


40431


c. On 1/30/24 at 1245 hours, an interview and concurrent review of Patient 8's medical record was conducted with Nurse Manager 3.

Patient 8's medical record showed Patient 8 presented to the Trauma ED on 1/28/24 at 1231 hours, for head injury. At 1244 hours, Patient 8 was triaged with the acuity level "3."

Review of the ED Note-Provider dated 1/28/24 at 1344 hours, showed Patient 8 had head injury.

Review of the Assessment showed Patient 8 was assessed on 1/28/24 at 1334 and 1440 hours.

Review of the Discharge Documentation dated 1/28/24 at 2116 hours, showed Patient 8 was transferred to the Psych ED. The patient's pain level was eight out of 10. The patient's vital signs were taken at 2113 hours.

There were no documented evidence showing Patient 8 was assessed every four hours as per the hospital's P&P.

Nurse Manager 3 confirmed the findings.

d. Review of Patient 9's medical record was conducted with Nurse Manager 3 on 1/30/24 at 1315 hours.

Patient 9's medical record showed Patient 9 came to the ED on 8/31/23 and discharged on 9/1/23 2033 hours.

Review of the ED Triage/Intake dated 9/1/23 at 0244 hours, showed Patient 9 was triaged with the acuity level "3."

Review of the Discharge Documentation showed Patient 9's vital signs were taken on 8/31/23 at 1955 hours; 8/31/23 at 2321 hours; 9/1/23 at 0244 hours; 9/1/23 at 0444 hours; and 9/1/23 at 0738 hours.

Review of the ED Vital Signs and Pain showed Patient 9's vital signs were assessed on 9/1/23 at 1437 hours, or approximately seven hours later.

There were no documented evidence showing Patient 9's vital signs were assessed every four hours as per the hospital's P&P.

Nurse Manager 3 confirmed the findings.

3. On 1/30/24 at 1215 hours, an interview and concurrent review of Patient 7's medical record review was conducted with Nurse Manager 3. When asked how often the patients with the acuity level 2 would be reassessed for vital signs, Nurse Manager 3 stated every two hours.

Review of the Emergency Department Trauma/Resuscitation Flowsheet dated 1/28/24, showed Patient 7 arrived to the ED at 1555 hours.

Review of the ED Note - Provider dated 1/28/24 at 1610 hours, showed Patient 7 had self-inflicted neck stab wound.

Review of the ED Trauma Triage dated 1/28/24 at 1702 hours, showed Patient 7 was triaged with the acuity level "2."

Review of the Vital Signs showed Patient 7's vital signs were taken on 1/28/24 at 1634, 1645, and 1700 hours.

Review of the ED Clinician Discharge Summary dated 1/28/27 at 2039 hours, showed Patient 7 was discharged from the ED on 1/28/24 at 2039 hours.

There were no documented evidence showing Patient 7's vital signs were taken every two hours.

Nurse Manager 3 confirmed the findings.

4. Review of the hospital's P&P titled Emergency Crash Cart Exchange Program dated 10/22/19, showed the Emergency Crash Cart Checklist located in the Crash Cart Inventory/Log Book on the top of the emergency cart will be checked every shift by nursing personnel.

On 1/29/24 at 0915 hours, a tour of the Psych ED was conducted with Nurse Manager 3. A crash cart was observed in the Psych ED.

Review of the Emergency (Crash Cart) Equipment Check Log showed the nursing staff did not check the crash cart on 1/23/24 day shift, 1/26/24 night shift, and 1/28/24 day shift.

The finding was confirmed by Nurse Manager 3.

Based on interview and record review, the hospital failed to ensure the ED staff completed the Psychiatric Patient Transfer Acknowledgment and Consent form when transferring one of 20 sampled patients (Patient 12) to other facility. This failure had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving ED services.

Findings:

Review of Patient 12's medical record was initiated on 1/30/24.

Patient 12's medical record showed Patient 12 came to the ED on 10/1/23 and was transferred or discharged to other facility on 10/1/23 at 2217 hours.

Review of the Psychiatric Patient Transfer Acknowledgment and Consent form showed on 10/1/23, showed the following:

* Patient 12 was transferred to the outside facility because there was no bed at the transferring hospital.

* The comments section showed if a patient refuses to sign, check one of the following boxes

- Patient cites his/her right to refuse to sign the form.

- Patient denies any reason for psychiatric hospitalization.

- Patient is acutely agitated and unable to sign.

- Other (specify)

However, these boxes were not checked.

* The sections of Patient/Parent/or Legal Representative Signature and Date/Time were left

On 1/30/24 at 1300 hours, an interview and concurrent review of Patient 12's medical record was conducted with Nurse Manager 3. Nurse Manager 3 confirmed the Psychiatric Patient Transfer Acknowledgment and Consent form was not completed for Patient 12.