HospitalInspections.org

Based on document review, medical record review, and staff interview, the facility failed to ensure registered nurses supervised and evaluated the nursing care for each patient when:
a. three patients (Patients #2, 8, and 10) with complaints of pain, were not appropriately managed and/or reassessed for pain.
b. Patient #2's abnormal vital signs were not addressed and Foley catheter was not assessed.
Findings were:

a. Facility policy number 23996 titled "Pain Management" stated in part, "Purpose: To provide clinical guidance in facilitating the effective pain management of patients thereby enhancing their comfort, function, outcomes, and personal/family satisfaction. Pain management is an organizational priority.
Policy: 1) As an organization, Ardent recognizes the patient's right to the appropriate assessment, management and reassessment of pain. Caregivers from all disciplines will acknowledge, assess, and document, as appropriate, throughout the continuum of care the patient's self-report of pain or observable responses to pain utilizing cognitively and age appropriate pain scales.
Procedure: 1) Orders for management of pain will be based on the patient diagnosis, assessment and/or reassessment. The plan of care may contain both pharmacological and non-pharmacological treatments for patient pain or discomfort.
2) The assessment and reassessment will take into account the individual patient's response to treatment, both physiologically and emotionally.
...Nursing staff: ...c) If pain is present, the initial physical assessment should include a comprehensive pain assessment based on patient self-report. Factors may include, but are not limited to, the following parameters: ...iv) Based upon observations and collaboration with physician, pain medication will be administered appropriately.
v) Utilize available pharmacological interventions prescribed and consider using non-pharmacological relief techniques ...
vii) Reassessment/Evaluation should occur:
(1) ...following any intervention intended to lessen the patient's pain ..."

Review of the medical record for Patient #2 revealed they presented to the ER on 11/20/21 at 8:02 pm for Left leg pain. On 11/20/21 at 8:13 pm, Patient #2's pain was assessed as a level 10 out of 10. There were no interventions to decrease pain. There was no reassessment of pain prior to discharge.

Review of the medical record for Patient #8 revealed they presented to the ER on 12/31/21 at 2:35 pm for foot pain and had a pain assessment of 9 out of 10 at 2:20 pm. There were no interventions for pain, but pain was reassessed at a level of 9 at 10:21 pm. The patient was discharged at 12:13 am with no reassessment of pain and no interventions to decrease pain.

Review of the medical record for Patient #10 revealed they presented to the ER on 12/22/21 at 2:55 am for a motor vehicle crash. Patient #10 had a pain assessment of 4 out of 10 at 5:08 am and received Toradol [a nonsteroidal anti-inflammatory medication used to treat pain] 15 mg IV [milligrams intravenously] at 5:54 pm. Patient #10 discharged at 7:07 am, there was no reassessment of pain after interventions or prior to discharge.

In an interview on 2/9/22 at 12:00 pm with Staff #5, regarding Patient #2's pain, Staff #5 stated, "Nurse came in and assessed [Patient #2's] pain as '10' according to the pain scale at 8:13 pm and I do not see another one. Normally, a prudent nurse, when doing vital signs on their patient would ask [about pain]." When discussing Patients #2 and #8, when asked what the expectation was when a patient arrives with and complains of pain, Staff #5 stated, "We can't order anything. All we can do is let the doctors know. We should document the doctors were notified."

b. CDC [Centers for Disease Control and Prevention] Recommendations titled "Guideline for Prevention of Catheter-Associated Urinary Tract Infections (2009)" found at https://www.cdc.gov/infectioncontrol/guidelines/cauti/recommendations.html stated in part, "V. Administrative Infrastructure
A. Provision of guidelines
1. Provide and implement evidence-based guidelines that address catheter use, insertion, and maintenance.
...B. Education and Training
1. Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training regarding techniques and procedures for urinary catheter insertion, maintenance, and removal. Provide education about CAUTI, other complications of urinary catheterization, and alternatives to indwelling catheters.
...D. System of documentation
1. Consider implementing a system for documenting the following in the patient record: indications for catheter insertion, date and time of catheter insertion, individual who inserted catheter, and date and time of catheter removal."

Facility policy number 23091 titled "Vital Signs and Documentation Guideline" stated in part, "**Implementation of nursing guidelines should not interfere with prompt physician notification and intervention when warranted**
Reassessment of vital signs
*Vital signs should be assessed upon triage and reassessed as patient condition warrants
...Abnormal discharge vital signs should be reported to ED physician prior to patient leaving department."

Review of the medical record for Patient #2 revealed they presented to the ER on 11/20/21 at 8:02 pm for Left leg pain. Patient #2's Oxygen Saturation levels [level of oxygen in blood; normal level = greater than 90%] during stay were:
11/20/21:
-8:05 pm: 91%
-9:11 pm: 90%
-11:15 pm: 88%

11/21/21:
-12:00 am: 88%
-12:55 am: 89%
-1:45 am: 91%
-3:30 am: 91%
-7:45 am: 88% (this was the last set of vital signs taken. Patient #2 left the facility on 11/21/21 at 1:16 pm)

Nursing note dated 11/21/21 at 1:15 pm stated in part, "pt [patient] family member demanded the foley catheter placed in [another facility] be removed. We removed the foley catheter per family request and placed patient in the car."

In an interview with Staff #5, ER nurse, and Staff #6, ER Director, on the morning of 2/9/21, when discussed patient #2's issues related to no reassessment of oxygen saturation and no information on the foley, Staff #5 referred to the medical record and stated, "[Patient #2's] highest was 91%." Staff #6 stated, "It should be reassessed - was the probe out of place, did it need to be readjusted, was this an accurate reading? It should be reassessed. They're supposed to validate that [reading]." When asked what validate means, Staff #5 stated, "The Vital Signs are automatic, they show up in the nurse's chart and has 'data not validated.' They need to make sure it's correct and validate it. I don't know why they didn't address it." When asked about the documentation regarding the foley, Staff #5 stated, "The foley is not assessed anywhere. Drains should have been addressed as 'present on arrival' then they would document they d/c'ed it."

The above findings were discussed and verified with the Manager of Regulatory Compliance and Director of Patient Safety on the afternoon of 2/9/22.