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NORTH COUNTRY HOSPITAL AND HEALTH CENTER 189 PROUTY DRIVE NEWPORT, VT 05855 April 22, 2015
VIOLATION: PATIENT CARE POLICIES Tag No: C0271
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and record review, care and services were not provided in accordance with the CAH's currently established policies and procedures for 3 of 10 patients who presented to the ED (Emergency Department) for evaluation and treatment. (Patients #1, #2 and #8). Findings include:

1. Per record review staff failed to reassess, prior to discharge, the blood pressure and pain level for Patient #1, who presented to the ED at 3:40 PM on 3/5/15 with complaints of lower back pain. During the initial nursing triage to assess the patient's condition, his/her blood pressure was noted as elevated at 193/67 and the patient self identified his/her back pain as 9 out of ten on the Numeric Pain Scale (with zero being no pain and 10 the worst pain). The acuity of the patient's condition was identified as a Level 3, which, according to the CAH's currently established procedure for FIVE LEVEL TRIAGE CLASSIFICATION, (most recent review date 2014), "Requires two or more resources, and/or vital signs are abnormal." Despite the abnormally elevated blood pressure there was no evidence it had ever been reassessed prior to the patient's discharge. Diagnostic testing revealed a possible fracture in the patient's spine, and although a Lidoderm patch was applied and the patient received 1 Vicodin tablet for pain management, there was no evidence that the patient's pain level had been reassessed in accordance with the facility's established Pain policy, (most current review date 2014) which stated; "North Country Hospital Standard of Practice. PROCEDURE. 1. Patient will have baseline pain assessment on admission...3. Patient will have pain assessed prior to pain medication or intervention and a reassessment within 'l hour of having pain medication or intervention...."

During interview, at 11:00 AM on 4/22/15, the ED Nurse Manager confirmed the lack of reassessment of pain and blood pressure for Patient #1 and stated both should have been reassessed prior to the patient's discharge from the ED.

2. Per 4/22/15 record review, staff failed to reassess the pain level of Patient #2, who (MDS) dated [DATE] with reported 10/10 bilateral leg pain, prior to discharge from the ED. On 2/27/15 at 7:16 AM, the Nursing Triage assessment noted that Patient #2 "appears uncomfortable... slightly distressed ...crying ...complains of pain in the right leg, left leg, back of left leg and back of right leg ...Reports pain that is 10 out of 10 on a pain scale" (with zero being no pain and 10 the worst pain). The patient's 7:31 AM medical examination noted [DIAGNOSES REDACTED] (redness), swelling and tenderness in both the right and left legs and Patient #2 was diagnosed with [DIAGNOSES REDACTED]#2's pain was reassessed after those interventions as per the facility's Pain policy (referenced above).

On 4/22/15, at approximately 11:10 AM, the ED Clinical Nurse Manager confirmed that Patient #2's pain had not been reassessed per policy prior to discharge from the ED.

3. Per record review staff failed to assure a report was made to the appropriate State Agency (SA), following an ED visit by a patient under 18 years of age who alleged abuse by a guardian, in accordance with the CAH's currently established policy for ABUSE - REPORTING SUSPECTED CHILD ABUSE OR NEGLECT, most recently reviewed in 2014. The policy stated: "Expectations of Employees with Regard to Reporting....All employees, regardless of whether they are mandated reporters, who observes, becomes aware of, or has reason to suspect child abuse or neglect,...shall report to the Department for Children and Families, Child Welfare & Youth Justice Division (DCF, formerly known as SRS) within 24 hours. Employees should report to DCF directly even if a family member or other person has reported the incident. It is DCF's responsibility to investigate and sort out different versions of the same incident..." Patient #8, who presented on the evening of 4/6/15 following involvement in a domestic altercation, had an ED Physician note which indicated that the patient had reported there had been an argument with one of his/her guardians and the guardian allegedly hit the patient with an object. Despite the allegation by the patient there was no evidence that any staff involved with the patient's care reported this allegation to the responsible SA.

The ED Nurse Manager confirmed, during interview at 3:20 PM on 4/22/15, that the incident had not been reported to the responsible SA.
VIOLATION: QA - QUALITY OF PATIENT CARE Tag No: C0336
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

The Quality Assurance Program (QA) failed to identify the lack of pain reassessment and the opportunity for improvement during a quality review of a patient complaint about care and services received during an Emergency Department visit (Patient #2). Findings include:
Per 4/22/15 record review, Patient #2 (MDS) dated [DATE] with reported 10/10 bilateral leg pain. The Nursing Triage assessment at 7:16 AM noted that Patient #2 "appears uncomfortable... slightly distressed ...crying ...complains of pain in the right leg, left leg, back of left leg and back of right leg ...Reports pain that is 10 out of 10 on a pain scale" (with zero being no pain and 10 the worst pain). The patient's 7:31 AM medical examination noted [DIAGNOSES REDACTED] (redness), swelling and tenderness in both the right and left legs and Patient #2 was diagnosed with [DIAGNOSES REDACTED]#2's pain was reassessed after those interventions in accordance with the facility's Pain policy (most current review date 2014) which stated; "North Country Hospital Standard of Practice. PROCEDURE. 1. Patient will have baseline pain assessment on admission...3. Patient will have pain assessed prior to pain medication or intervention and a reassessment within 1 hour of having pain medication or intervention...."
On 4/22/15, at approximately 11:10 AM, the ED Clinical Nurse Manager (NM) confirmed that Patient #2's pain had not been reassessed per policy prior to discharge from the ED. The NM also confirmed that following Patient #2's ED visit, a friend called on the same day to report concerns over the care that Patient #2 had received in the ED, stating that s/he "was not treated well and was told to try to stay still, which [s/he] could not, due to the pain [s/he] was in." The NM confirmed asking to speak to Patient #2 but was told that [s/he] "had just settled down after not being able to sleep for days due to pain."
Per 4/22/15 interview at 1:45 PM, the Director of Quality and Patient Safety reported that when patient complaints come in, department managers are expected to investigate by reviewing the medical record to determine what had occurred during the visit and to see if the identified issues can be resolved. S/he confirmed that although pain was identified as an issue in the complaint, Patient #2's lack of pain reassessment in the ED had not been identified and brought to the QA department as a potential opportunity for improvement following the complaint investigation.