HospitalInspections.org

Based on medical record review, policy review, and staff interview, the facility failed to follow their policies to obtain vital signs and to assess patient pain levels. This affected three (#1, #2 and #10) of ten patients reviewed who received services in the emergency department.

Findings:

1. The medical record revealed Patient #1 was admitted to the emergency department (ED) on 03/31/24 at 6:44 PM with complaints of sharp upper abdominal pain for the past three days and vomiting times one. This patient stated her pain was frequent and non-radiating. The acuity level of a three was given at 6:54 PM with vital signs (VS) completed listing a temperature (T) of 97.8 degrees Fahrenheit (F), heart rate (HR) of 101, respiratory rate (RR) of 18, blood pressure (BP) of 147/95, and a pain rating of 10 out of 10. The physician was at the bedside at 7:01 PM and ordered tests and medications to be given. This patient was medicated with Protonix 40 milligram (mg) intravenous (IV) and Bentyl (antispasmodic) at 7:47 PM then Zofran (anti-nausea) at 7:53 PM. Patient # 1 was discharged home at 9:01 PM with instructions to follow up with their physician and return if pain increased. The medical record contained no documentation of any additional vital sign monitoring or any pain assessment after being medicated.

Review of the facility policy titled "Emergency Department Triage Process (ESI and Vital Signs}," revised 08/24, instructs staff in the emergency department to assess patients for chief complaint, vital signs (VS) including pain assessment, and determine a emergency severity index (ESI). Vital sign guidelines are by ESI scoring. With a ESI score of one complete VS every five to fifteen minutes, ESI score of two will have VS completed every 30 minutes for the first four hours, ESI score of three will have VS every hour for the first four hours. This policy further states if a ED patients are in the department longer than one hour they must have their VS completed at discharge.

Review of the facility policy titled "Pain Management," dated 05/11/23, states if pain is identified on assessment the following components should be assessed to include location, intensity rating, description, onset, duration and pattern, aggravating and or alleviating factors, current pain management interventions and establish a comfort goal with patient. A pain reassessment should be completed after each pain management intervention (pharmacologic and non-pharmacologic) in a timely and comprehensive manner appropriate to the circumstances. For pharmacological pain interventions reassess the patient for pain intensity and side effects to evaluate the medication effect dependent on the medication peak and route of administration.

Interview on 1/14/24 at 1:30 PM, the Manager of the ED, Staff F, verified no documentation was found of a pain reassessment and no repeat VS were completed per policy.

2. The medical record revealed Patient #2 was admitted to the ER on 11/28/24 at 3:11 PM with complaints of right sided chest pain that increased when taking deep breaths. The history and physical listed endometriosis and polycystic ovarian syndrome (PCOS) with an exploratory laparotomy for endometriosis completed on 11/21/24 at a different hospital. At 3:23 PM Patient #2 stated they've been having right lung pain since surgery, felt short of breath, and complained of an increase in pain when they took a deep breath. An acuity level of three was assigned at 3:25 PM and VS were documented as T-98.5 degrees F, HR 79, RR 14, BP of 148/73 with no documentation of a pain score completed.

An assessment was completed by the certified nurse practitioner (CNP) with the lungs documented as clear with no wheezing, heart rate had regular rhythm, normal pulses and abdomen was soft and non-distended. Patient stated she has pain to the lateral right chest which was worse with a deep breath and improves when she was up and moving around. Patient stated she has tried Tylenol, ibuprofen, and Norco at home with no relief. Patient describes pain as the feeling of "Running a marathon in minuse 20 degree weather."

The pain medication Toradol 60 mg was given intramuscularly (IM), Zofran 4 mg orally, and a gastrointestinal (GI) cocktail which consisted of viscous of lidocaine and Maalox solution at 4:23 PM. The first pain scoring of 4/10 was documented at this time.

Patient # 2 was discharged home at 5:15 PM with instructions to follow up with their primary care physician and to return to the ED if symptoms get worse. There was no evidence of any pain reassessment being completed after being medicated for pain.

Interview on 01/14/25 at 3:15 PM, Staff F verified the findings of not documenting an initial pain score or re-assessment of pain per policy.

3. The medical record revealed Patient #10 was admitted on 09/16/24 at 9:15 PM with complaints of chest pain which started three days ago. An acuity level of two was assigned at 9:19 PM, and the physician was in to see the patient at 9:20 PM. Vital signs were recorded at 9:21 PM with T of 97.7 degrees F, HR 102, RR -13, BP 134/90, and chest pain rating of 6 out of 10. Orders were placed at 9:26 PM for medications and at 9:45 PM the patient was give a chewable baby aspirin 324 mg, protonix 40 mg IV, and Bentyl 20 mg IM. Patient #10 was discharged home with instructions at 10:58 PM with instructions to follow up with the cardiologist. The record contains no additional vital signs and no further assessment of the patient's pain levels. .

Interview on 01/14/25 at 3:30 PM, Staff F verified Patient #10's record had no documentation vital signs were repeated every 30 minutes and prior to discharge. Staff F also verified no documentation was found the pain was assessed per the policy.