HospitalInspections.org

Based on document review, medical record (MR) review and interview, 1) in 4 of 10 MRs, Patient #1- #4, Emergency Department (ED) nursing staff did not document vital signs and patient reassessments per hospital policy and procedure (P&P). 2) In 1 of 10 MRs Patient #1 ED nursing staff did not document procedures performed. 3) In 3 of 10 MRs, Patient #1, #3, and #4, ED nursing staff did not document pain level and pain reassessment. This could cause staff to be unaware of a patient's condition.

Findings regarding 1) above:

-- Review of the hospital's P&P titled "Triage & Assessment of ECU (Emergency Care Unit) Patients," last revised 2/2015, indicated the registered nurse should evaluate and categorize each patient upon arrival to the ED into one of five triage levels: Class 1-Resuscitation, Class 2-emergent, Class 3-Urgent, Class 4-Semi-urgent and Class 5-Non-urgent. Each class requires a certain level of monitoring. For example, Class 2 patients should be reassessed every 30 minutes until evaluated by a physician, then as needed according to physician orders. Class 3 patients should be reassessed every 60 minutes until evaluated by a physician, then as needed according to physician orders. Repeat vital signs as per triage category.

-- Review of Patient #1's MR revealed on 10/5/19 at 9:25 am, he presented to the ED with chief complaint of nausea, vomiting and abdominal pain. Nursing triaged him at 9:33 am as a Class 2. Vital signs were, blood pressure (B/P) 104/60, temperature (T) 97.9 Fahrenheit (F), pulse (P) 52, respirations (R) 18, oxygen saturation (SpO2) 96%. Nursing assessment at 10:12 am revealed patient was alert, in moderate distress, breath sounds normal, pulses steady and equal, bradycardia. Vital signs were B/P 116/68, P 51, R 20, SpO2 93%. At 12:22 pm vital signs were B/P 122/70, T 97.7 F, P 63, R 24, SPO2 92%. Vital signs and nursing reassessments were not documented per hospital P&P.

-- Review of Patient #2's MR revealed she presented to ED on 1/13/20 with chief complaint of vaginal bleeding. She was triaged at 10:35 am as a Class 3. Vital signs were B/P 96/66, T 98.2 F, P 78, R 18, SpO2 100%. Nursing assessment done at 11:35 am revealed Patient was alert, anxious, normal breath sounds, no contractions, no vaginal bleeding and no edema. Vital signs were next documented at 3:12 pm (4 1/2 hours later) as B/P 108/66, P 78, R 16, SpO2 98%. Vital signs and nursing reassessments were not documented per hospital P&P.

-- Review of Patient #3's MR and Patient # 4's MR revealed both lacked documentation of vital signs and nursing assessments per hospital P&P.

-- Per interview of Staff A, ED Nurse Manager on 10/16/20 at 9:52, he/she indicated that patients vital signs for Class 2 should be obtained every 30 minutes, Class 3, every 60 minutes and Class 4 should be every 120 minutes.

-- During interview of Staff B, Vice President of Nursing on 1/16/20 at 2:00 pm, he/she acknowledged the above findings.

Findings regarding 2) above:

-- Review of the hospital's P&P titled "Triage & Assessment of ECU (Emergency Care Unit) Patients," last revised 2/2015, indicated the registered nurse should document procedures (e.g., Foley, nasogastric (NG) tube, Labs, X-Ray, etc.).

-- Review of Patient #1's MR revealed on 10/5/19, at 12:38 pm that Staff C, Surgeon ordered an NG tube at 1:40 pm. Staff D, Anesthesiologist documented at 1:40 pm that NG tube was in place.

-- Per telephone interview of Staff E, ED RN on 1/16/20 at 12:30 pm, he/she recalled providing care to Patient #1 in the ED. He/she recalled placing the NG tube, checking for proper placement (by auscultation) and connecting the NG tube to low intermittent suction. He/she stated a large amount of gastric contents emptied into the suction canister. Staff E recalls working on documentation in the MR.

There is no documentation in the MR regarding NG tube placement, assessment of correct placement, amount and description of gastric suction contents.

-- During interview of Staff B on 1/16/20 at 2:00 pm, he/she acknowledged the above findings.

Findings regarding 3) above:

-- Review of the hospital's P&P titled "Pain Management," last revised 2/2015, indicated in the ED, a pain screen is performed upon admission. If pain is present, a pain assessment is performed and repeated each time the patient complains of pain. A reassessment is performed after each pain intervention, based on the action of the medication, which will vary depending upon route of administration. In general, reassessment is recommended within 1 hour of medication administration or prior to departure from the ED whichever comes first.

-- Review of Patient #1's MR revealed he presented to the ED on 10/5/19 with chief complaint of nausea, vomiting and abdominal pain. At 11:45 am he received 50 mcg of Fentanyl IV (no pain level was documented). At 12:13 pm he received 50 mcg. Fentanyl IV (no pain level was documented). At 12:33 pm he received 4 mg Morphine IV (no pain level was documented). Pain assessments and reassessments were not documented per hospital P&P.

-- Review of Patient #3's MR, revealed on 10/29/19 at 5:15 pm she was triaged with chief complaint of pain in right arm and elbow after falling off a swing. Pain was 4 out of 10. At 7:42 pm Motrin was administered to Patient. There is no documentation of pain level at that time. Patient was transferred to another hospital at 8:47 pm. There was no documentation of a pain reassessment as required by hospital P&P.

-- Review of Patient #4's MR also revealed lack of pain assessment and reassessment per hospital P&P.

-- During interview of Staff B on 1/16/20 at 2:00 pm, he/she acknowledged the above findings.