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Based on clinical medical record reviews, policy reviews, and staff interviews, the facility failed to follow facility policy for monitoring patients hourly in the ED (Emergency Department) and failed to follow facility policy for pain assessment monitoring for 1 of 3 patients sampled (Patient #1).

Findings include:

Policy #1400 entitled "General Guidelines For Emergency Department Patients" , dated 7/04, under III. D. states, vital signs for trauma patients: 1. "A minimum of hourly blood pressure (BP) , pulse (P), respiration (R), and Glasgow Coma Scale (GCS) will be documented for: a. All level I and level 2 trauma patients. c. Patients who are admitted to the hospital with a trauma related diagnosis. 2. This encompasses arrival time to time of discharge from the ED, including time away from the department."

Policy #347 entitled "Luther Midelfort Statement On Treatment Of Pain, dated 4/01, states the following for ALL PATIENT CARE DEPARTMENTS, under II A. II. Patients with pain can expect: A. Initial pain assessment and regular reassessment of pain: 1. With report of pain. 2. After each pain management intervention once sufficient time has elapsed for treatment to reach peak effect. Under D. the policy states, that assessment of pain includes the following: 1. Pain intensity (using a pain intensity rating scale appropriate to the patient). 2. Location. 3. Additional assessment data may include (as appropriate to scope of services): a. Pain quality (including patterns of radiation, if any, and character). b. Onset, duration, variations, and patterns. c. Alleviating and aggravating factors. d. Present pain management regimen and effectiveness. e. Pain management history (including medication history, presence of common barriers to reporting pain and using analgesics, past interventions and response, manner of expressing pain). f. Effects of pain (impact on daily life, function, sleep, appetite, relationships with others, emotions, concentration, etc.). g. Patient's pain goal (including pain intensity and goals related to function, activities, and quality of life). h. Physical exam/observation of site of pain."

Per medical record review of Patient #1 by Surveyor #05409 beginning at 10:55 a.m. on 9/30/10, the following was noted:

Per review of ED (Emergency Department) nursing notes, Patient #1 came into the ED at 5:15 a.m. on 8/7/10. RN F triaged Patient #1. The triage note documented at 5:24 a.m. states triaged at 5:15 a.m. chief c/o (complaint) pain lower back at 8 (out of 0 to 10 scale). Unwitnessed fall at home. Abrasions right lower back/bruising right arm and skin tear right lower leg. Vital signs were taken. The initial pain assessment is incomplete as it lacks type of pain (i.e. burning, stabbing, etc.) or what alleviates or exacerbates the pain. RN F did not monitor Patient #1's pain thoroughly.

Per interview with RN F on 10/7/10 from 10:00 a.m. to 10:25 a.m. RN F states that facility policy is to include a description of the pain, and what makes it better or worse. RN F verified in this interview that F did not document a complete pain assessment during the primary/initial assessment. Per RN F, F asked #1 if wanted anything for pain and Patient #1 said no. Daughter of Pt. #1 said had given #1 Tylenol prior to coming to ED, but RN F verified that F did not ask or assess the strength or dose of the Tylenol Patient #1 took prior to coming to the ED. (Per review of medication history Patient #1 has an order for Tylenol 500 mg 2 tablets at bed time). RN F verified that F was not aware if regular Tylenol tablets of 325 mg or 500 mg tablets were administered to Patient #1 prior to coming to the ED. RN F stated that Patient #1 complained of pain in #1's lower back on the right by #1's hip. RN F verified that facility protocol is to monitor ED patients at least every hour at a minimum including vital signs and pain.

Per review of the initial ED Physician note on 8/7/10, Dr. E examined Pt. #1 and stated, "Took Tylenol prior to coming in and does not desire any further pain medication at this time." Dr. E ordered right hip x-rays for Pt. #1.

Patient #1 had x-rays of the right hip done at 5:49 a.m. on 8/7/10 which did not show fracture. Patient #1 was discharged home at 6:22 a.m.

Dr. E was interviewed by Surveyor #05409 from 1:35 p.m. to 1:46 p.m. on 9/30/10 and E verified that E did not know which kind of Tylenol or how much was given to Patient #1 prior to this ED visit. Dr. E verified that this was not monitored in "E's " assessment.

Pt. #1 returned to the ED at 9:20 a.m. on 8/7/10. At 9:24 a.m. Pt. #1 was triaged by RN D with Chief complaint of generalized pain after a fall this morning at 3:00 a.m. RN D documented that Pt. #1 was having increased pain in the waist area. Shooting pain 10/10 (10 out of 0 to 10 scale with 10 being the worst). Primary assessment entered by RN D at 9:45 a.m. states at 9:42 a.m. right and left upper and lower lungs clear, but diminished. Respirations nonlabored. Vital signs were documented.

Dr. G performed an exam at 9:49 a.m. including monitoring #1's pain and G ordered chest x-rays to be done.

At 9:59 a.m. Pt. #1 was given 5mg of Morphine by nursing subcutaneously (a shot) for pain.

At 10:27 a.m. a chest x-ray was done by Dr. C and the following was noted per review of the x-ray report: acute nondisplaced 6th and 7th rib fractures. No pneumothorax. Emphysematous changes in both lungs (emphysema).

At 10:37 a.m. Pt. #1 ' s vital signs were rechecked (heart rate, blood pressure, temperature, respirations, and oxygenation.

At 10:38 a.m. pain was monitored by RN D per nursing notes and the pain was at a " 2 " in Pt. #1's right lower back. RN D did not monitor a description of the pain.

Per flow sheet review, at 11:26 a.m. vital signs were monitored, but no pain monitoring was done and there is no documentation of the effectiveness of the Morphine that was given at 9:59 a.m. as per facility policy.

At 12:47 a.m. the next set of vital signs were taken per the nursing flow sheet (1 hour and 21 minutes later than the last check). Pain was not monitored since 10:38 a.m. Vital signs and pain were not monitored as per facility policy.

At 1:30 p.m. Pt. #1 was given 10 ml of Vicodin elixir orally for pain, as per the nursing flow sheet. A nursing note documented by RN D at 1:30 p.m. states that the Vicodin had been given due to D's reporting to the physician that Pt. #1 had increased pain with movement. No pain assessment was documented by RN D at this time in the nursing notes or on the flow sheet (last documentation of a pain assessment was done at 10:38 a.m.).

Per review of the flow sheets, at 2:03 p.m. Pt. #1' s vital signs were reassessed, but pain was not monitored. Per flow sheets, at 3:11 p.m. Pt. #1 ' s vital signs were rechecked, but pain was not monitored. Per flow sheets, at 4:23 p.m. vital signs were reassessed (1 hour and 12 minutes since the last check) Pain was not monitored. Staff did not follow facility policy for monitoring.

Per ED preliminary physician notes at 4:25 p.m. Dr. H examined Pt. #1 and noted lungs were clear. Pain was noted in the rib areas, but no complete pain assessment was documented. Dr. H ordered a CT scan (computer type x-ray) of Pt. #1' s abdomen.

Per review of radiology reports, at 4:58 p.m. a CT scan was done which revealed more rib fractures: 10th, 11th, and 12th ribs were also fractured, totaling 5 rib fractures. A small to moderate right pneumothorax (puncture to the right lung) was also noted.

An addendum was added to the 4:25 p.m. preliminary report by Dr. H which stated that a chest tube was to be inserted.

Per review of flow sheets, the next vital sign check of Pt. #1 was done at 6:27 p.m. (previous check was done at 4:23 p.m.- almost 2 hours prior). A thorough pain assessment was not monitored since 10:38 a.m.

Per review of flow sheets, at 6:41 p.m. vital signs were rechecked and Pt. #1 was given 1 mg of Morphine in the IV, but pain was not monitored/assessed.

Per flow sheets, at 7:10 p.m. Pt. #1 was given another 1 mg of Morphine in the IV, but no pain assessment/monitoring was done.

Per flow sheets, at 7:13 p.m. 1 mg of Midazolam was given to Pt. #1 in the IV to sedate #1 for chest tube placement and the chest tube was placed at 7:29 p.m. in Pt. #1's right chest.

Per review of nursing documentation, at 9:10 p.m. Patient #1 was taken to the neuro-intermediate care unit for admission.

No further vital signs were monitored since 6:27 p.m. and no pain was monitored since 1:30 p.m. An actual pain assessment was not done since 10:38 a.m.

As above, Pt. #1 was sedated at 7:13 p.m. for chest tube placement and vital signs were not monitored after the procedure in the ED.

Per interview with Director B and Safety Director A from 10:25 a.m. to 11:10 a.m. on 10/7/10, A & B confirmed that Pt. #1 was considered a trauma patient and should have had vital signs and pain monitored at least every hour while in the ED. A & B verified the above findings during this interview.