HospitalInspections.org

Based on document review and interview, it was determined in 5 of 10 (Pt #s 1, 3, 4, 5 and 8) the Hospital failed to ensure patients were assessed and reassessed, as required while in the Emergency Department (ED).

Findings include:

1. Hospital policy entitled, "Patient Assessment and Reassessment, (ED CHS - 32)" (revision date 12/01/14) required, "Action steps: A. Upon presentation to the ED a qualified medical person performs a triage assessment per Emergency Department Triage and Treatment Guidelines. B. Assessment by a RN upon admission to the ED treatment area will be based on...and include at a minimum, the following: 3. Pain if present..C. Patient acuity and needs determine the frequency of reassessment...Reassessment of patient care needs...is also initiated at the following times: 1. When there is a significant change in the patient's condition...4. Upon transfer discharge from the ED..."

2. An interview was conducted on 12/16/14 at approximately 11:00 AM with the Director of the Emergency Department. The Director stated that ED follows the Hospital wide policy for pain management.

3. Hospital policy entitled, "Pain Management, (CHS Nursing D - 55)" (dated 1/06/14) required, "Scope: It is the responsibility of all clinical staff to assess and reassess the patient for and relief from pain including the intensity, quality...and responses to treatment.."Action Steps: Pain Management - All Patients; A. Assess for presence of pain for all patients: 1. Initial comprehensive assessment...2. Reassessment/Ongoing pain assessment...B. Pain is reassessed at appropriate intervals following interventions and/or medications with appropriate documentation...5...the RN can address pain and/or reassess the pain following intervention to determine effectiveness. (refer to Patient Care Bundle policy C-24)."

4. Hospital policy entitled, "Patient Care Bundle (CHS Nursing C - 24)," (revision date 02/02/14) required, "Hourly Rounding: A. Rounding by unit clinical staff will occur on all patients every hour from 6a - 10p and every 2 hours from 10p - 6a...B. Rounding will utilize the following 8 key behaviors...4. Address the 4 'P's' of pain..."

5. The clinical record of Pt. #1 was reviewed on 12/16/14. Pt. #1 was a 90 year old female that presented to the ED on 9/15/14 at 7:03 AM as a triage level 3. Patient #1 presented with a chief complaint of fall (chin laceration, right shoulder pain). Upon admission, Pt. #1's pain was not documented as assessed; however, Pt. #1 received 2 milligrams of Morphine (pain medication) at 7:37 AM. Pt. #1 subsequently received 15 millileters of Hydrocodone (pain medication) without documentation of an assessment or reassessment of pain.

6. The clinical record of Pt #3 was reviewed on 12/16/14. Pt #3 was a 60 year old male that presented to the ED on 10/21/14 at 10:53 AM as a triage level 4. Pt #3 presented with a chief complaint of fall. Pt #3 received 1 milligram of Dilaudid (pain medication) intramuscularly at 1:09 PM for an admission pain scale of 10/10. Pt #3's clinical record lacked documentation of a reassessment of Pt #3's pain level. Pt #3 was discharged at 4:10 PM; however, Pt #3's clinical documentation lacked a reassessment of his pule, respirations and temperature.

7. The clinical record of Pt #4 was reviewed on 12/16/14. Pt #4 was a 43 year old female that presented to the ED on 12/9/14 at 12:05 PM. Pt #4 presented with a chief complaint of fall. Pt #4 was discharged home on 12/9/14 at 1:30 PM without documentation of vital sign reassessment (blood pressure, pulse, respiration, and temperature).

8. The clinical record of Pt #5 was reviewed on 12/16/14. Pt #5 was an 82 year old female that presented to the ED on 11/9/14 at 3:12 PM. Pt #5 presented with a chief complaint of fall two (2) weeks ago. Triage documentation included a pain level of 9/10. Pt #5 was discharged home on 11/9/14 at 7:26 PM without documentation of vital sign and pain reassessments (blood pressure, pulse, respiration, and temperature).

9. The clinical record of Pt #8 was reviewed on 12/16/14. Pt #8 was an 18 year old male that presented to the ED on 9/24/14 at 8:12 PM. Pt #8 presented with a chief complaint of left collar bone fracture. Pt #8 was discharged home on 9/24/14 at 8:35 PM without documentation of vital sign reassessment (blood pressure, pulse, respiration, and temperature).

10. On 12/16/14 at approximately 1:30 PM the Clinical Nurse Manager of Emergency Department and Clinical Decision Unit was interviewed. The Manager stated that the clinical records should have included reassessments of pain and discharge vital signs.

11. On 12/18/14 at approximately 9:30 AM the Director of Emergency Department stated that pain assessments and vital signs should have been documented. The director stated, "Documentation is a problem currently in the emergency department."