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Based on staff interview, review of facility documents, and review of medical records, it was determined the facility failed to ensure comprehensive pain assessments and reassessments are completed, in accordance with facility policy.

Findings include:

Facility policy titled "Nursing Assessment Documentation", last reviewed, 9/6/24, states, " ...Policy: The Registered Nurse (RN) in the ED will utilize the Emergency Department Nursing Assessment Record (EHR) to document nursing assessment and interventions related to the care of the patient. ...Procedure: ...The Emergency Department RN will document on the Emergency Department Assessment Record (EHR) the following guidelines: ...Vital Signs, Pain, ...".

Facility policy titled "Pain Assessment- All Ages", last reviewed 10/21/24, states, " ...Responsibility: Emergency Department RN Policy: It is policy of [facility name] that all patients have a right to pain assessment and management. ...Procedure: 1. All patients will be assessed for the presence/absence of pain. ... 2. Pain will be assessed at the point of triage using an appropriate pain assessment scale based upon chronological or developmental age. ...6. Reassessment: Evaluate response to medication at the appropriate interval, in reducing pain to a level that is acceptable to the patient. Suggested time intervals include: - 1 hour for PO [oral] analgesia, sub-cutaneous, or IM [intramuscular] analgesia -15 minutes for intravenous analgesia -1-2 hours after all non-pharmacological interventions (heat, cold, position changes, relaxation, etc.) ...".

On 11/14/24, medical record review revealed the following:

Patient (P)6 presented to the Emergency Department (ED) on 11/11/24 at 3:44 PM, with a chief complaint of ankle sprain. P6 was triaged at 3:56 PM, and had a pain score of 7/10. At 7:05 PM, P6's pain score was 7/10, and oral Percocet 5-325 mg (milligrams) was administered. P6's medical record lacked documentation that a pain intervention was implemented upon triage and that a pain reassessment was completed one (1) hour after the administration of pain medication.

P7 presented to the ED on 1/9/24 at 3:49 PM, with a chief complaint of abdominal pain and vomiting. P7 was triaged at 9:21 PM with a pain score of 8/10. At 2:06 AM, P7's pain was reassessed with a pain score of 4/10 and oral Tylenol 650 mg was administered. P7 was discharged at 2:13 AM. P7's medical record lacked documentation that a pain intervention or reassessment was completed after triage.

P8 presented to the ED on 1/20/24 at 12:32 PM with a chief complaint of wrist pain and laceration. P8 was triaged at 1:36 PM. His/her medical record lacked documentation of an initial pain assessment. At 2:02 PM, P8's pain score was a 10/10. At 2:17 PM, 4 mg Morphine IV (intravenous) was ordered, but not administered. At 4:50 PM, P8's pain reassessment was 7/10. P8 was discharged at 4:56 PM. P8's medical record lacked documentation that pain medication was administered, or that a pain intervention was implemented.

P9 presented to the ED on 2/29/24 at 9:26 AM with a chief complaint of left hip pain status post fall. P9 was triaged at 9:44 AM. His/her medical record lacked documentation of an initial pain assessment. At 11:30 AM, P9's pain score was 9/10. At 11:30 AM, Morphine 4 mg IV was administered. P9 was transferred to another facility at 3:43 PM. P9's medical record lacked documentation that a pain reassessment was completed (1) hour after the administration of pain medication.

P10 presented to the ED on 10/2/24 at 12:44 PM for evaluation status post fall. P10 was triaged at 2:12 PM. His/her medical record lacked documentation of an initial pain assessment. At 5:53 PM, P10's pain score was 3/10 and oral Ibuprofen 600 mg was administered. P10 was discharged at 7:10 PM. P10's medical record lacked documentation that a pain reassessment was completed one (1) hour after pain medication administration.

P11 presented to the ED on 3/6/24 at 12:00 AM with a chief complaint of abdominal pain and vomiting. P11 was triaged at 12:13 AM. P11's medical record indicated P11 was "dismissed" at 1:05 AM. P11's medical record lacked documentation that a pain assessment was completed upon triage.

P12 presented to the ED on 10/13/24 at 3:46 PM with a chief complaint of ankle pain status post fall. At 3:55 PM, P12 was triaged with a pain score of 9/10. P12 received intramuscular Toradol 30 mg for pain at 4:28 PM. At 7:12 PM, P12's pain reassessment score was 6/10 and oral Tylenol 1000 mg was administered. P12 was discharged at 7:30 PM. P12's medical record lacked evidence that a pain reassessment was documented within one (1) hour of pain medication administration.

On 11/15/24 at 2:00 PM, an interview was conducted with Staff (S) 4, ED Director. S4 stated that pain should be assessed during the initial nursing triage and reassessed within one hour after pain medication administration.

The above findings were confirmed with S4.

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to implement policies and procedure for the care of suicidal patients presenting to the Emergency Department.

Findings include:

Facility policy titled, "Nursing Assessment Documentation," reviewed, 9/6/24, states, " ...Policy: The Registered Nurse (RN) in the ED will utilize the Emergency Department Nursing Assessment Record (EHR) to document nursing assessment and interventions related to the care of the patient. ...Procedure: ...The Emergency Department RN will document on the Emergency Department Assessment Record (EHR) the following guidelines: Initial Nursing/Triage Assessment...Suicide Assessment... ."

Facility policy titled, "Suicide Precautions", reviewed 10/21/24, states, " ...PURPOSE: To ensure a safe environment for potentially self-destructive patients and to establish guidelines for staff observation of these patients. RESPONSIBILITY: Emergency Department Staff POLICY: Each patient triaged will be screened for suicidal and homicidal ideations. If a patients answer is yes to having suicidal ideations, constant observation (1:1) will be triggered. PROCEDURE: 1. Suicide precautions will be ordered by the physician, but nursing staff will implement suicide precautions while awaiting the order. 2. Patients shall be placed in one of the safer rooms located in bed #20, or #FT 2 3. The "Safer Room" Checklist will be complete by the primary RN (see attached). 4. 1:1 Observation will be initiated following guidelines of the 1:1 Policy ... ."

Facility policy titled, "One to One (1:1) Observation/Close Observation (CO)," revised 12/21, states, " ...Procedure: ...2. 1:1 Observation: The patient shall be observed on a 1:1 staff/patient ratio when clinical assessment indicates immediate or impulsive behavior that may be harmful to self or others. ...Documentation: 1. An order for a One to One Constant Observation will be written in the medical record by the MD/APN [medical doctor/advance practice nurse] only. ...2. The Frequent Observation Flow Sheet must be started as soon as the patient is placed on one to one (1:1). An entry must be made every 15 minutes. ...3. Safe Environment Documentation: A. Emergency Room staff will complete The Emergency Room Safe Environment Risk Assessment Tool prior to patient placement in a treatment area. ... ."

On 11/15/24 medical record review revealed the following:

Patient (P)1 presented to the Emergency Department (ED) on 5/18/24 at 6:42 AM with an arrival complaint of Suicidal Ideation. P1 was assigned to Room 05 in the ED. At 6:56 AM, the Chief Complaint Updated states, "Suicidal (Brought by EMS from [facility name] nursing home, reported pt [patient] verbalizing wants to kill self, that [he/she] does not want to stay in that nursing home, reported that staff noted pt tried to used [sic] belt to hurt [himself/herself])." At 6:58 AM, P1's Columbia Suicide Severity Rating Scale (C-SSRS) score was "High Risk," and P1 answered "yes" to suicidal thoughts. At 7:12 AM, P1's belongings were taken to the utility room. At 9:12 AM, P1 was transferred to Room 06. At 9:19 AM, P1's C-SSRS score was "Moderate Risk." At 9:37 AM, the ED Provider Note stated, " ...Psychiatric/Behavioral: Positive for behavioral problems and suicidal ideations. ...Comments: Suicidal Ideation - "I will hurt myself if I have to return to the nursing home" ...Patient medically cleared for psychiatric evaluation ... ." At 10:35 AM, the Psychiatric Consultation Note, states, " ...On evaluation this morning at the ED, ... [He/she] stated that [he/she] hung up [his/her] belt in anger and realized that it was wrong to do so. ...[He/she] reports a history of auditory hallucinations, hearing voces [sic] telling [him/her] to hit or attack anyone at times but [he/she] does not pay attention to them. ... "I love myself, I can never kill myself," [he/she] stated. On assessment, [he/she] denied auditory and visual hallucinations, denied suicidal or homicidal thoughts or plans or actions. ...Plan: Patient psychiatrically cleared for discharge. ... ." P1 was discharged back to the nursing home at 12:54 PM.

P1's medical record lacked evidence of a physician's order for 1:1 observation. P1's medical record lacked documentation of the "Special Precautions/Observation Record," which is used to document the 1:1 observation. P1's medical record lacked evidence that an "Emergency Room Safe Environment Risk Assessment Tool" was completed. P1 was assigned to ED Room's 05 and 06, which are not "safer rooms" that P1 should be assigned to, in accordance with facility policy.

P1 presented to the ED again on 9/2/23 at 3:13 PM, with a chief complaint of Weakness. P1 was assigned to Room 15. At 3:55 PM, the Chief Complaint Updated, states, "Suicidal (Patient BIBA (brought in by ambulance) from [town]. EMS [Emergency medical services] from [town name]. EMS reports, patient was found wandering around lost. Patient states to RN [Registered Nurse] 'I want to kill myself. I feel very depressed and do not want to live anymore.)' ... ." At 4:54 PM, P1's belongings were searched and placed into a locker/storage area. At 5:20 PM, P1 was medically cleared for psychiatry. On 9/2/24 at 10:19 PM, P1's Psychiatric Consult Note stated, " ...Patient states recently when [his/her] blood pressure is high and [he/she] gets angry [he/she] wants to kill [himself/herself] but does not really mean it and never has had a plan, nor has [he/she] ever attempted suicide. Patient currently denies suicidal ideations and has contracted for safety. ...Plan: ...Patient is cleared psychiatrically and does not need psychiatric hospitalization at this time. The [emergency room] to provide outpatient psychiatric follow up for this patient." On 9/2/24 at 11:20 PM, P1 was assigned to Room 20. On 9/3/23 at 8:10 AM, P1's C-SSRS score was low risk. On 9/3/24 at 9:24 AM, P1 was discharged. P1's medical record, had a scanned in 1:1 observation document titled "Special Precautions/Observation Record," dated 9/2/24, from 4:00 PM until 11:30 PM.

P1's medical record lacked evidence that a suicide screening was completed on the initial nursing/triage assessment when P1 presented to the ED on 9/2/23. P1's medical record lacked evidence of a physician's order for 1:1 observation and lacked evidence that an "Emergency Room Safe Environment Risk Assessment Tool" was completed. P1 was assigned to Room 15, which is not a "safer room" that P1 should be assigned to, in accordance with facility policy.

P3 presented to the ED on 2/8/24 at 7:28 PM, with a chief complaint of alcohol intoxication and suicidal ideation. At 7:43 PM, the ED RN Note stated, "1:1 in place for safety. Pt changed into blue scrubs all belongings removed from patient." On 2/9/24 at 2:53 PM, the Psychiatric Consult stated, " ...Plan: ...Pt does not meet any inpt [inpatient] psychiatric commitment criteria at this time. ...Pt is psychiatrically cleared at this time... ." P3 was discharged on 9/3/24 at 4:38 AM.

P3's medical record lacked evidence of a physician's order for 1:1 observation. P3's medical record lacked documentation of the "Special Precautions/Observation Record" which is used to document 1:1 observation.

On 11/18/24 at 12:00 PM, these findings were confirmed with S4 (ED Director).