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Based on record review, staff interview and review of policy/procedures the facility failed to ensure one Emergency Room patient (Patient 2) had pain control prior to discharge and that the physician was notified of critical lab values for one patient (Patient 7) from a sample of 10 patients. This has potential to affect any patient with pain and critical lab values.

Findings are:

A. A review of Patient 2's medical record revealed, the patient returned to the Emergency Room (ER) for the 2nd time on 9/4/20 at 5:51 AM per the rescue squad. The patient complained of pain to the patient's right knee at a level of 10 out of 10 (10 being the worst pain ever or severe). [The patient had been in the ER prior to this visit on 9/4/20 from 0043-0238 (12:43 AM- 2:38 AM) following a fall at the Assisted Living Facility. The patient was treated for a laceration to the ear, abrasion to the lip and bruising to the right knee and returned to the Assisted Living Facility at 2:38 AM.]

Upon Pt 2's return to the ER on 9/4/20 at 5:51 AM the assessment completed at 6:12 AM by the Registered Nurse (RN) A revealed:
-Vital Signs: Temperature 97 degrees; Pulse 65; Respirations 16; Blood Pressure 206/85 and Oxygen Saturation 98%.
-Alert and Oriented
-PAIN SCALE: 10
-Presenting problem: complaint of right knee pain from previous fall 3 hours ago. The onset was gradual, the patient has guarded movement and grimacing.
-The patient describes the pain as aching and sharp; exacerbating factors was movement, positioning, weight bearing and standing.

Review of Dr D's physical assessment of Patient 2 upon return on 9/4/20 at 5:51 AM revealed:
-The patient was complaining of some discomfort in the right knee but was able to go to the bathroom 3 times during the earlier visit to the ER. The patient now has pain. The patient and family deny that something more happened to knee between leaving here and going back to the care facility and children were with the patient and there was no additional fall.
-The patient can bend toes; bend the ankle; bend the knee; there is the old bruising that was seen originally but appears to be 5-7 days old and there has not been any new fall. Will do an x-ray of the knee and make sure there is no obvious evidence of fracture. Clinically the Dr can rotate the hip internally, externally flex and extend at the knee; and palpate the kneecap without discomfort.
-The x-ray was read by Dr D, and showed no evidence of fracture.

The Patient was dismissed back to the Assisted Living Facility at 8:04 AM on 9/4/20. The orders included: do not bare weight on the right leg for 1 week; follow up with physician as needed; use the bedpan or bedside commode for 1 week; wheelchairs for transfers.

On 9/4/20 at 11:58 AM, Pt 2 returned to the hospital for admission due to intractable and intolerable pain after an Assisted Living Facility visit by Nurse Practitioner (NP E). NP E ordered pain medication Tramadol (pain medication for moderately severe pain) 50 mg (milligrams) 3 times a day; a knee immobilizer; physical and occupation therapy. The patient was discharged back to the Assisted Living Facility on 9/14/20 with the ability to get out of bed with a standby assistance only; ambulating with therapy and the right knee pain is tolerable.

The ER visit on 9/4/20 from 5:51 AM - 8:04 AM on 9/4/20 was reviewed with the Chief Nursing Officer (CNO) on 7/7/21 at 2:30 PM. The CNO verified that the medical record lacked a repeat Pain assessment; any medications given for pain and the Dr D did not order any additional medication on discharge for pain control at the Assisted Living Facility.

Review of the Policy titled "Pain Management" last approval by the medical staff on 6/17/08 revealed:
-The patient is the authority on pain.
-Pain Assessment Scale NRS (Numeric Rating Scale); 0- no pain through 10 being most severe or worst pain ever.
-Measurement of outcomes should reflect timely, appropriate interventions and achievement of desired outcomes.

B. A review of Patient 7 medical record revealed, the patient came to the Emergency Room (ER) on 4/14/21. The patient arrived after falling at home. Patient 7 was assessed by Dr G and lab was ordered. Pt 7 was found to have a urinary tract and acute renal insufficiency. Dr G ordered a Myoglobin (A lab test that indicates there has been very recent injury to skeletal or cardiac muscle.) The patient was admitted to the hospital for care and treatment.

Review of Patient 7's laboratory report for the Myoglobin drawn at 12:40 PM on 4/14/21. The report shows the critical result of 1472 was called to ER. The normal range for Myoglobin is 0-82 ng/ml (nanogram per milliliter- a unit of measure in laboratory tests). The ER record lacked .documentation that the nurse or physician acknowledged the critical level. A repeat Myoglobin was drawn on 4/15/21 at 6:29 AM. The report shows the critical result of 231 was called to the nurses station at 7:20 AM. The record lacked documentation that the nurse notified the physician upon notification of the critical lab. The physician progress note did acknowledge the lab result at 8:24 PM on 4/15/21.

The Director of Nurses verified on 7/8/21 at 10:30 AM that Pt 7's medical record lacked documentation of immediate physician notification of critical lab values.

Review of the Policy titled "Reporting Abnormal Lab Values" last revised 12/2005 revealed:
1)Abnormal lab values will be starred for easier identification.
2)The following are a list of lab values that are considered critical. The lab will contact the charge nurse and she/he will contact the physician immediately. The lab person will document the time and to whom they reported. The charge nurse will document the time the physician contacted. If the patient's is unavailable, the on call physician will be notified.