HospitalInspections.org

Based on document review and interview, the registered nurse failed to ensure reassessments of pain following the administration of pain medications were completed according to facility policy for 1 of 5 patients (P#1) and failed to ensure admission orders were initiated in emergency department as required per policy.

Findings included:

1. Review of the medical record of P#1 on 5-6-13 indicated the following: On 3-14-13 at 2327 hours, P#1 rated their pain at 9 on a scale of 0-10; Toradol 30 mg IV was given at 2344 hours; pain is documented as reassessed on 3-15-13 at 0120 hours as a 4 (0-10), 1 hour and 53 minutes. Pain is documented as reassessed on 3-15-13 at 0245 hours as a 7 (0-10); 1 hour and 25 minutes; the medical record lacked documentation pain was reassessed or other means of pain relief provided for pain prior to leaving the Emergency Department and arriving in the Intensive Care Unit at 0425 hours.
2. Review of facility policy titled PAIN MANAGEMENT GUIDELINES on 5-6-13 indicated the following: Pain reassessment must be documented in either hourly rounding or pain assessment/med/management screen post pain medication.
3. An interview was conducted on 5-6-13 at 1450 hours who confirmed pain reassessment is not documented in the hourly rounding/post pain medication for P#1 as required by facility policy.
4. Review of physician orders on 5-6-13 for P#1 indicated a C-PAP was ordered on 3-15-13 at 0250 hours with 100% oxygen; documentation lacked evidence the C-PAP was applied prior to the patient requiring intubation and ventilator support at 0452 hours (2 hours and 22 minutes after the C-PAP order was written).
5. Review of the medical record of P#1 on 5-6-13 indicated the patient had an order for admission to the Intensive Care Unit written on 3-15-13 at 0230 hours, the bed was unavailable due to not being cleaned, and the patient remained in the Emergency Department (ED) until 0425 hours when the ICU bed was available.
6. Review of facility policy titled HOLDING/BOARDING PATIENTS IN THE EMERGENCY DEPARTMENT on 5-6-13 indicated the following: All standard admission orders will be initiated in the ED by the RN as soon as possible.
7. An interview was conducted on 5-6-13 with B#2 at 1450 hours who confirmed the admission orders were not initiated in the ED by the RN, including the C-PAP as required by facility policy.
8. An interview was conducted on 5-6-13 with B#5 at 1455 hours who confirmed the C-PAP order was not initiated in the ED as required by facility policy.
9. An interview was conducted on 5-6-13 at 1500 hours with B#1 who confirmed the C-PAP order was not initiated in the ED as required by facility policy.