HospitalInspections.org

Based on a review of documentation, policies and interviews with the Facility Staff, the facility failed to provide vital sign assessment after administration of hydromorphone solution 1mg, Once IV on 12/17/2023 from 4:30 PM to 5:16 PM. Hold for Resp Rate < 10 or Systolic BP < 100.

The Findings were:

A review of the document titled Patients Medical Record dated 12/14/2023 documents administration of hydromorphone solution 1mg, Once IV on 12/17/2023 from 4:30 PM to 5:16 PM. Hold for Resp Rate < 10 or Systolic BP < 100.
Vital Signs on 12/17/2023 at 4:19:
BP: 171/92, Pulse: 131, Resp: 20, Temp: 98F Temporal artery, SpO2: 99% on room air.
Pain was documented by Staff # 2, RN-ED as a level 10 at 4:18 PM. Pain was at a level 10 at 4:55 PM. No additional pain assessments, interventions or vital signs was documented. Effectiveness of medication was not documented.
Pulse was documented at 95 at 8:13 PM. No additional vitals documented.

A review of the facility's Policy titled, "Assessment, Reassessment, and Documentation - Attachment B, Emergency Department (ED)" section 1.3.3 and 1.3.3 subsect c, page 2
"Vital signs are defined as: blood pressure, temperature (temporal artery only appropriate for those
minor complaint ESI 4 & 5), pulse, respiratory rate, oxygen (02) saturation percentage and 02
delivery type, Glasgow Coma Scale (GCS), and pain level.
c. ESI 3- stable, requiring multiple resources needed to treat.
Vital signs(*** Core temperature recommended) and Glasgow Coma Scale (GCS) during triage and subsequently every two hours at a minimum, or at discharge. Patient condition may require more frequent reassessments. *Reassessment completed with any change in patient condition."
The facility failed to follow this policy when nursing did not obtain vital signs every two hours at a minimum or at discharge.


An interview with Staff # 6, John Dinnen, RN-ED on 02/13/2024 at approximately 10:35 AM revealed the following:
Surveyor: What is an auto restart of vitals timer?
RN-ED: I can set a timer for vital signs to be rechecked for anywhere from 15 min to every two hours.
Surveyor: When would you document the effectiveness of Dilaudid?
RN-ED: I would check in 5 to 10 minutes. That is a very strong narcotic.
Surveyor: If a patient reported a pain level of 10/10 twice in an hour, what would your next step be?
RN-ED: I would notify the doctor.
Surveyor: Would you continue to assess the patient for pain?
RN-ED: Yes, I would assess the pain level at different time intervals depending on the medication administered, or every 2 hours if the patient is stable.

A phone interview with Staff # 1, Dr. Justin Brady Evans, MD-ED on 02/13/2024 at approximately 12:45 PM revealed the following:
Surveyor: Why did you make the choice to discharge the patient home rather than admit to the hospital for surgery?
MD-ED: After medication she was stable, she no longer had pain to her abdomen. I felt she was low for an emergency surgery risk. I knew a surgeon would not see her at the ED and maybe not the following day if symptoms remained relieved. Her labs and lactic acid were good. She was discharged home with a surgeon referral and instructions to return to the ED if symptoms change or worsen.
Surveyor: Did the patient ask for her surgeon to be called?
MD-ED: Not that I remember. She did say she was unable to contact her surgeon. "I believe I put the surgeon referral in as urgent, to speed up the process but her case was not an emergency at that time."
Surveyor: Do you recall the patient requesting her discharge medication to be sent to a different pharmacy than the one on the discharge sheets?
MD-ED: No, there were no concern or changes requested or made. If I make a change, I make a note in the patient's medical chart. If she called the ED at a later time the unit clerk or Charge Nurse has a form for the MD-ED to follow-up with the next morning.