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Based on documentation review the Hospital failed to ensure that: 1. Emergency Department (ED) physician documentation was dated and timed for 7 of 11 medical records (Patient #1; Patient #4; Patient #7; Patient #8; Patient #9; Patient #10, and Patient #11), and 2. pain reassessment was appropriately documented for 1 of 11 patients (Patient #4).

Findings included:

1. The Department of Emergency Medicine Documentation Sheet and Clinical Record were preprinted forms completed by the ED physicians and other providers such as residents and physician assistants.

Review of the Emergency Medicine Documentation Sheet and Clinical Record indicated that there were no spaces requiring physicians to document the date/time.

Review of the medical records for: Patient #1, dated 11/8/10; Patient #4, dated 12/2/10; Patient #7, dated 11/8/10; Patient #8, dated 11/7/20; Patient #9, dated 11/10/10; Patient #10, dated 11/9/10, and Patient #11, dated 11/8/10 indicated that physician documentation was not dated or timed.


2. Review of the Hospital's Policy/Procedure titled Pain Assessment and Reassessment, effective 3/1/10, indicated the following: a comprehensive pain assessment shall be conducted for any patient reporting or suspected of having pain. The assessment included the intensity of pain using a pain scale when practical. A reassessment for the presence of pain shall be performed at least once every 12 hours for inpatients, any complaint of pain, and following interventions (within 30-60 minutes) intended to reduce pain.

Although the policy's reassessment section referred to inpatients there was no indication in the policy that reassessment requirements were different for the Emergency Department.

Review of Patient #4's Emergency Department (ED) documentation, dated 12/2/10, indicated that Patient #4 presented to the ED at approximately 4:30 P.M. with abdominal distention and diarrhea. Documentation indicated that Patient #4 was alert and oriented. Documentation indicated that at approximately 4:40 P.M. Patient #4 reported abdominal pain rated as 8/10 (on a scale of 0-10; 0 represents no pain and 10 represents the worst possible pain) which improved after passing flatus. There was no documentation to indicate what the improved level of pain was.

Review of ED documentation, dated 12/2/10 to 12/3/10, indicated that a nasogastric tube was inserted to decompress the stomach and removed several hours later. Documentation indicated that Patient #4 was up ambulating or was resting comfortable and tolerating oral fluids. Orders were written for Patient #4 to be admitted to the Hospital.

Review of ED documentation indicated that there was no further documented reassessment of pain until 12/3/10 at 7:25 A.M. at which time Patient #4 refused pain medication. The level of pain was not documented. Documentation indicated that at 8:25 A.M. Patient #4 rated the level of pain as 4/10 and was administered Percocet as ordered.