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GEORGE WASHINGTON UNIV HOSPITAL 900 23RD ST NW WASHINGTON, DC 20037 Jan. 3, 2013
VIOLATION: PATIENT RIGHTS: PARTICIPATION IN CARE PLANNING Tag No: A0130
Based on medical record and policy review as well as interview it was determined that the hospital staff failed to uphold patients ' right to participate in care planning as evidenced by the nursing staff ' s failure to assess and/or intervene regarding pain management in the Emergency Department in four (4) of ten (10) records reviewed (Patients 1, 2, 8, and 9).

The findings include:
The George Washington University Hospital Emergency Department policy entitled Triage and Front-end Processing Protocol, effective date August 2012 was reviewed. Section V, entitled Procedure stipulates " 1. Greet Team: The greet team is composed of one greet (triage) RN, one ED technician to perform quick registration, and one runner technician ...a. The greet nurse obtains only the necessary information needed to obtain an ESI level and documents the chief complaint and ESI in the EMR ...2. Front End Team: The front end team is composed of variable numbers of RNs and ED technician depending on the time of day. The front end team will be responsible for the following functions: a. An RN will complete the ED triage nursing database; b. An RN will initiate front-end patient processing protocols for applicable patients waiting of ran available room ... "

The George Washington University Hospital Emergency Department policy entitled Triage and Front-end Processing Protocol, effective date August 2012, Appendix B - GW ED front-end patient processing protocols provides guidance for nursing intervention and follow-up of various presenting complaints. Regarding Generalized Abdominal Pain, the appendix stipulates " ...Intervention: Consider NPO [nothing by mouth], Heat pack ...Medication: Zofran 4 [four] milligrams by mouth for one dose ...Follow-up: Recheck medication effectiveness within one hour of administration; Notify MD of EKG result; Routine Rounding. "

The George Washington University Hospital Emergency Department policy entitled Triage and Front-end Processing Protocol, effective date August 2012, Appendix B - GW ED front-end patient processing protocols stipulates the following guidance for nursing intervention and follow-up regarding Flank Pain " Nursing Intervention: Insert peripheral IV - saline lock; Medications: Notify MD for appropriate pain control ... "

The George Washington University Hospital policy entitled Pain Management, effective date January 2012 was reviewed. Section II - Policy stipulates " ...B. All patients will be assessed for pain: 1. Upon admission ...5. All patients should be 5 or less or tolerable as defined by the patient ... C. Comprehensive pain assessment includes: 1. Pain score ... 8. Pain level tolerable/acceptable to the patient ... "

The George Washington University Hospital policy entitled Pain Management, effective date January 2012 was reviewed. Section III - Procedure stipulates " ... 3. For those patients found to be experiencing pain, an immediate initial, comprehensive pain assessment is to be performed and documented by the LIP/Clinician [Licensed Individual Provider]. 4. A treatment plan must be developed and implemented for any patient experiencing pain rated at 5 or above. The effectiveness of the treatment plan must be evaluated and documented ... "

Patient 1 presented to the Emergency Department (ED) on October 26, 2012 at approximately
5:27 PM. Greet Triage was performed at approximately 5:34 PM resulting in an assigned acuity Triage Level of three (3), indicative of urgent. The record lacked documented evidence of a pain assessment at Greet Triage given the chief complaint of Abdominal Pain.

Patient#1 subsequently received a Front-end Triage at 6:16 PM on October 26, 2012. The front-end triage lacked documented evidence of pain and skin assessments. Patient#1 was examined by the physician at 7:46 PM, and reported pain level at ten of ten (10/10).
The medical record lacked documented evidence that Patient #1 was offered the opportunity to participate in her care plan through the use of comfort measures or other medications which would not interfere in diagnostic procedures as per hospital policy.

On November 3, 2012 Patient#1 presented to the ED with a chief complaint of Abdominal Pain, Diarrhea and Vomiting. The patient was ' greet triaged ' at 8:39 PM and assigned an acuity level of urgent/three (3). The patient reported a pain level of ten of ten (10/10), indicative of the worst possible pain. The patient was subsequently ' front end ' triaged at 8:52 PM, and continued to report a pain level of ten of ten (10/10).

The medical record lacked documented evidence that the nursing staff intervened to provide pain relief for the patient, or that the patient was offered the opportunity to participate in her care plan through the use of comfort measures or other medications which would not interfere in diagnostic procedures as per hospital policy and protocol.

The hospital staff failed to uphold the patient ' s right to participate in care planning through the failure to assess and/or intervene regarding pain and pain management in a timely fashion.

The findings were discussed with the ED Clinical Supervisor on January 3, 2013 at approximately 11:30 AM. The Clinical Supervisor stated that the expectation is that patients will be fully screened for pain levels, to include information regarding acceptable pain levels; and appropriate interventions should be initiated as soon as possible to assure comfort.

Patient 2 presented on November 3, 2012 with a chief complaint of Abdominal Pain with Vomiting at approximately 8:34 AM. Greet Triage was performed at approximately 8:34 AM resulting in an assigned acuity Triage Level of three (3), indicative of urgent. Patient#2 ' s pain level was assessed at seven of ten (7/10) indicative of moderate to severe pain.

The medical record lacked documented evidence that Patient #2 was offered the opportunity to participate in her care plan through the use of comfort measures or other medications which would not interfere in diagnostic procedures as per hospital policy and protocol.

The hospital staff failed to uphold Patient#2 ' s right to participate in care planning through the failure to assess and intervene regarding pain and pain management in a timely fashion.

The findings were discussed with the ED Clinical Supervisor on January 3, 2013 at approximately 11:30 AM. The Clinical Supervisor stated that the expectation is that patients will be fully screened for pain levels, to include information regarding acceptable pain levels; and appropriate interventions should be initiated as soon as possible to assure comfort.


Patient 8 presented on November 2, 2012 with a chief complaint of Abdominal Pain with Vomiting at approximately 2:45 PM. Greet Triage was performed at approximately 2:45 PM resulting in an assigned acuity Triage Level of three (3), indicative of urgent. The patient ' s pain level was assessed at seven of ten (7/10) indicative of moderate to severe pain.

The front-end triage was performed at 2:50 PM. The medical record lacked documented evidence that patient ' s pain level was assessed. Patient#8 was reassessed at 6:47 PM, at which time the patient ' s pain level was assessed at seven of ten (7/10) indicative of moderate to severe pain.

The medical record lacked documented evidence that Patient#8 was offered the opportunity to participate in the care plan through the use of comfort measures or other medications which would not interfere in diagnostic procedures during the initial assessment.

The record reflected that the patient was examined by the physician at 7:26 PM, and comfort measures were initiated at 8:10 PM. The patient received intravenous pain medication at 8:45 PM. The medical record reflected that Patient #8 ' s pain management plan was not implemented until greater than four hours after initial presentation.

The hospital staff failed to uphold the patient ' s right to participate in care planning through the failure to assess and intervene regarding pain and pain management in a timely fashion.

The findings were discussed with the ED Clinical Supervisor on January 3, 2013 at approximately 11:30 AM. The Clinical Supervisor stated that the expectation is that patients will be fully screened for pain levels, to include information regarding acceptable pain levels; and appropriate interventions should be initiated as soon as possible to assure comfort.


Patient 9 presented on November 2, 2012 with a chief complaint of Follow-up of Right Hip Pain at approximately 6:24 PM. Greet Triage was performed at approximately 6:24 PM resulting in an assigned acuity Triage Level of three (3), indicative of urgent. Patient #9 ' s pain level was assessed at ten of ten (10/10) indicative of severe or worst possible pain.

The front-end triage was performed at 7:34 PM. The record lacked documented evidence of a pain assessment at that time. The medical record lacked documented evidence that Patient #9 was offered the opportunity to participate in the care plan through the use of comfort measures or other medications which would not interfere in diagnostic procedures.

Patient #9 was examined by the licensed independent provider (LIP) at 8:22 PM and intravenous pain medication was ordered. At 9:02 PM the medication was administered and a follow-up assessment was performed.

The medical record lacked documented evidence that Patient #9 was offered the opportunity to participate in the care plan through the use of comfort measures or other medications which would not interfere in diagnostic procedures during the initial assessment.

The hospital staff failed to uphold the patient ' s right to participate in care planning through the failure to assess and intervene regarding pain and pain management in a timely fashion.

The findings were discussed with the ED Clinical Supervisor on January 3, 2013 at approximately 11:30 AM. The Clinical Supervisor stated that the expectation is that patients will be fully screened for pain levels, to include information regarding acceptable pain levels; and appropriate interventions should be initiated as soon as possible to assure comfort.
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on medical record and policy review as well as interview it was determined that the hospital staff failed to document all information necessary to monitor the patient ' s condition in the Emergency Department in one (1) of ten (10) records reviewed (Patient 1).

The findings include:

The George Washington University Hospital policy entitled Pain Management, effective date January 2012 was reviewed. Section III - Procedure stipulates " ... 3. For those patients found to be experiencing pain, an immediate initial, comprehensive pain assessment is to be performed and documented by the LIP/Clinician [Licensed Individual Provider]. 4. A treatment plan must be developed and implemented for any patient experiencing pain rated at 5 or above. The effectiveness of the treatment plan must be evaluated and documented ... "

The George Washington University Hospital policy #1601 entitled General Guidelines for Documentation, effective date July 2012 was reviewed. Section III - Policy stipulates " ... Types of Documentation - Patient Care Services staff document patient information in the medical record and/or flowsheets as appropriate to their job description; Frequent observations and treatments can be documented on a variety of flowsheets, graphic sheets, narrative notes, and computerized documentation assessments. "

The George Washington University Hospital policy #1602 entitled Documentation of Patient Assessment, effective date July 2012 was reviewed. Section C, Progress Notes/Patient Notes stipulates " ...1. Progress notes must document the following: a. A patient ' s response to therapy when the information is beyond that documented on the Shift Assessment, Clinical MAP, or flowsheets ....2. Nurses must complete a shift note every shift. The frequency of progress notes is determined by the patient ' s condition and response to prescribed therapies. Patients who are receiving active therapies should have an SBAR note that refers to the plan of care (as directed in Plan of Care section above) documented at least once every 24 hours. "

Patient 1 presented to the Emergency Department (ED) on November 3, 2012 with a chief complaint of Abdominal Pain, Diarrhea and Vomiting, and assigned an acuity level of urgent/three (3). Patient #1 consistently reported pain level of ten of ten (10/10), indicative of the worst possible pain for the first three (3) hours of the admission. Patient #1 was subsequently treated for pain at 11:03 PM, with reassessment at 11:34 PM.

According to hospital staff, a downtime for the electronic medical record occurred at 12:00 AM lasting until 6:00 AM. During the downtime, the ED staff initiated the use of downtime forms to document the continuance of patient care.

The nursing staff failed to document all information necessary to monitor the patient ' s condition during the downtime to include nursing notes which evidence care plans, vital signs, and reports of treatments.

The findings were discussed with an ED Clinical Supervisor on January 3, 2013 at approximately 11:30 AM, and again with another ED Clinical Supervisor on January 15, 2013 at approximately 7:45 AM. Both Clinical Supervisors acknowledged and confirmed the finding. The first Clinical Supervisor stated that the expectation is that nursing staff will document all pertinent patient care in the medical record.