HospitalInspections.org

Intakes: TN00040858

Based on policy review, medical record review, observation and interview, the hospital failed to ensure nursing care assessments were conducted to identify the needs of 3 of 3 (Patient #1, 2 and 3) sampled patients.

The findings included:

1. Review of the facility's "Assessment/Reassessment/Plan of Care of Patients" policy revealed, "...Patients at the facility receiving...Emergency Department (ED) services will have an initial assessment and appropriate follow-up assessments based upon their individual needs...The goal of the assessment/reassessment process is to provide the patient the best care and treatment possible. The goals of the care planning process are to identify and prioritize care and treatment...All assessments provided by health care professionals will be based on and include...Data collected to assess the needs of the patient...Assessments/Reassessment Matrix...Area...Emergency Department Level 3: Urgent...Initial Admission Assessment & [and] Care Plannng [Planning] Completion Time Frame...Primary RN = < 30 minutes...Reassessment & Care Planning Time Frame...2-4 hours as condition warrants...Initial Assessment/Screening...The assessment process will be collaborative to facilitate, identify, and prioritize the patient's needs and determine care...The design, by health care providers of a discipline specific assessment includes but is not limited to the following...Pain management...Reassessment is focused toward the problem areas identified through the initial assessment...Care planning is focused toward the problem areas identified through the initial assessment and subsequent reassessments, and any new problems or complaints noted by the patient, family or caregivers..."

Review of the facility's "Pain Assessment and Reassessment, Management and Documentation" policy revealed, "...[named hospital] assesses, reassesses and manages its patients' pain consistent with scope of care, treatment, services and the patient's condition...Reassessment of pain after the administration of pain medication is dependent on several patient factors (age and disease process) and medication factors (drug, dose, route, absorption, onset, peak, etc (et cetera; and so forth))...the goal is to assess the effectiveness of pain medication within one hour of administration ...Pain Assessment (includes the following)...Frequency...Pain descriptors and indicators...Patient teaching...Documentation..."

2. Medical record review for Patient #1 revealed an arrival date to the ED on 3/8/17 at 8:39 PM with chief complaints of non-productive cough, generalized myalgia, headache, fever, and chills for 3 days. Patient #1 was admitted to the hospital with the diagnosis of Acute Pyelonephritis and left the ED on 3/9/17 at 9:32 PM. The "EMERGENCY PATIENT RECORD" dated 3/8/17 revealed, "...Priority: 3 [Emergency Severity Index (ESI)]...03/08/17...2045 [8:45 PM]...PT [patient] C/O [complained of] 9/10 [9 on a 1 to 10 scale] GENERALIZED PAIN...]...[signed by Nurse #1]...03/08/17 2225 [10:25 PM]...Pain intensity: 10...[signed by Nurse #2]..." The "MEDICATION DISCHARGE SUMMARY" dated 3/8/17 to 3/9/17 revealed, "...TYLENOL EXTRA STRENGTH 1,000 MG [milligrams] PO [by mouth] X [times] 1...03/09/17...0038 [12:38 AM]...GAVE: 1,000 MG...Pain intensity...9...[signed by Nurse #2]...REASSESS...[no reassessment documented]...KETOROLAC TROMETHAMINE [Toradol]...30 MG IV [intravenous] X 1...03/09/17...0052 [12:52 AM]...GAVE: 30 MG...Pain intensity: 8...[signed by Nurse #2]...REASSESS...[no reassessment documented]..." There was no reassessment of Patient #1's pain after the Tylenol and Ketorolac were administered. The next documented pain assessment was on 3/9/17 at 4:24 AM with a pain rating of 0 on a 1-10 scale (3 hours 32 minutes after the last pain medication had been administered).

The "EMERGENCY PATIENT RECORD" revealed, "...03/08/17 2040 [8:40 PM]...Temperature F [Fahrenheit]: 101.7...03/09/17 1039 [10:39 AM]...Temperature F: 103.7..." There was no temperature documented from 8:40 PM on 3/8/17 to 10:39 AM on 3/9/17 (13 hours 59 minutes].

3. Medical record review for Patient #2 revealed an arrival date to the ED on 1/10/17 at 12:43 PM with a chief complaint of headache. Patient #2 was admitted to the hospital with diagnoses of Headache and Chronic Back Pain Greater Than 3 Months Duration and left the ED on 1/10/17 at 7:00 PM The "EMERGENCY PATIENT RECORD" dated 1/10/17 revealed, "...Arrival Date/Time: 01/10/17 - 1243 [12:43 PM]...Triage Date/Time...01/10/17 - 1309 [1:09 PM]...Priority: 3 [ESI]...PT [patient] COMPLAINING OF A HEADACHE AND DIZZINESS SINCE AN EPIDURAL ON THURSDAY [5 days prior]...[signed by Nurse #3]..." There was no pain assessment documented in the triage assessment. The "EMERGENCY PATIENT RECORD" revealed, "...01/10/17...1441 [2:41 PM]...Pain intensity: 10..." The "MEDICATION DISCHARGE SUMMARY" revealed, "...DILAUDID...1 MG IV X 1...01/10/17...1458 [2:58 PM]...GAVE: 1 MG...Pain intensity: 10...[signed by Nurse #4]...REASSESS...[no reassessment documented]..." There was no reassessment of Patient #2's pain after the Dilaudid was administered. The next documented pain assessment was on 1/11/17 at 3:52 AM with a pain rating of 10 on a 1-10 scale (12 hours 54 minutes after the pain medication had been administered). During Patient #2's stay in the ED (on 1/10/17 from 12:43 PM to 7:00 PM (6 hours 17 minutes) there was only two documented pain assessments (at 2:41 PM and at 2:48 PM)).

4. Medical record review for Patient #3 revealed an arrival date to the ED on 3/6/17 at 10:32 AM with chief complaints of Diarrhea, Gastrointestinal (GI)/Abdominal Pain, and Body Cramps. Patient #3 was admitted to the hospital with diagnoses of Hypomagnesemia and Renal Insufficiency and left the ED on 3/6/17 at 11:12 PM. The "EMERGENCY PATIENT RECORD" revealed, "...Arrival Date/Time: 03/06/17 - 1032 [10:32 AM]...Triage Date/Time: 03/06/17 - 1040 [10:40 AM]...Priority: 3 [ESI]...PT STS [states] SHE HAD AN ILEOSTOMY SURGERY THREE WEEKS AGO AND HAS BEEN HAVING TROUBLE RETAINING FLUID...THIS MORNING STARTED HAVING DIARRHEA AND BODY CRAMPS...Chief Complaint: GI/Abdominal Pain...[signed by Nurse #3]..." There was no pain assessment documented in the triage assessment. The "MEDICATION DISCHARGE SUMMARY" revealed, "...DILAUDID...1 MG IV X 1...03/06/17...1148 [11:48 AM]...GAVE: 1 MG...Pain intensity: 8 [first documented pain assessment: 1 hour 16 minutes after arrival and 1 hour 8 minutes after triage]...[signed by Nurse #5]..." The "EMERGENCY PATIENT RECORD" revealed, "...03/06/17 1300 [1:00 PM]...Pain intensity: 7...[signed by Nurse #5]..." The "MEDICATION DISCHARGE SUMMARY" revealed, "...DILAUDID...1 MG IV X 1...03/06/17...1650 [4:50 PM]...GAVE: 1 MG...Pain intensity: 9..." There was no pain assessment documented from 1:00 PM to 4:50 PM (3 hours 50 minutes) on 3/6/17 after Patient #3 rated pain as a 7 on a 1-10 scale.

5. During an interview in the conference room on 3/21/17 at 7:52 AM, Nurse #2 stated nurses were to check vital signs and conduct pain assessments every hour in the ED. Nurse #6 stated when ED patients were admitted but still remained in the ED, nurses were to check vital signs and conduct pain assessments every 4 hours.

During an interview in the conference room on 3/21/17 at 8:02 AM, the ED Director stated nurses were supposed to conduct a pain assessment during triage and reassess pain within at least an hour after administering pain medication.

During an interview in the conference room on 3/21/17 at 10:30 AM, the ED Clinical Educator stated nurses should reassess patients in the ED every hour including pain assessment and full vital signs. The ED Clinical Educator stated nurses should conduct an initial pain assessment in triage, another pain assessment when the patient was brought back to a room and then another 30 minutes after the patient had arrived in the room. The ED Clinical Educator stated nurses should get all five vital signs (temperature, respiratory rate, pulse, blood pressure and oxygen saturation) at triage and every hour for any sign which is abnormal.