The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MEMORIAL MISSION HOSPITAL AND ASHEVILLE SURGERY CE 509 BILTMORE AVE ASHEVILLE, NC 28801 March 23, 2012
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on policy review, medical record review, and staff interview, the hospital's nursing staff failed to supervise and evaluate patient care by failing to assess pain per policy for 9 of 27 sampled Emergency Department (ED) patients (#30, #8, #7, #6, #15, #27, #10, #23 and #25).

The findings include:

Review of current ED policy entitled "Triage" dated 09/28/2008 revealed, "...Procedure:...6. Patients are assessed for the presence of pain during the triage process...."

Review of current hospital policy entitled "Nursing Pain Assessment and Management" dated 01/2011 revealed, "...Procedure: 1. Initial Assessment a. As part of the admission history, each patient is questioned about the presence of pain. b. If pain is present, a detailed assessment of the pain is completed which minimally includes location, intensity, and goal for relief (target score)....2. Ongoing assessment....c. When pain is identified the frequency of assessment is driven by the pain management plan and the patient's response to interventions. d. Pain assessment is completed when a PRN (as needed) intervention is provided to determine the appropriateness and effectiveness of the intervention....Hierarchy of Pain Assessment....I. Self-report....Tools: Adults: 0-10 scale and Verbal Descriptor....Pediatric, developmentally delayed, mentally handicapped: Wong-Baker FACES; 0-10 scale....III. Behaviors....Tools:...Pediatric: FLACC (Face, Legs, Activity, Cry, Consolability Scale)....5. Evaluation and Documentation a. Evaluation of response to intervention is performed within one hour of intervention and includes...if obtainable, a follow-up pain rating...."

1. Closed medical record review for Patient #30 revealed a 6 year-old male that presented to the ED via EMS (Emergency Medical Services ambulance) on 02/28/2012 at 1752 accompanied by his mother with chief complaint of "seizure today". Record review revealed documentation the triage nurse assessed the patient at 1800. Review of the triage nurse's assessment revealed no documentation the patient was assessed for pain. Record review revealed the patient was treated and subsequently discharged to home with a diagnosis of [DIAGNOSES REDACTED]

Interview on 03/20/2012 at 1510 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Further interview on 03/21/2012 at 1140 revealed the manager expected to see Wong-Baker or FLACC assessment tools used for the assessment of pain in pediatric patients. Interview confirmed there was no available documentation the patient was assessed for pain during the triage assessment or during the remainder of the ED visit (4 hours and 12 minutes).

2. Closed medical record review for Patient #8 revealed a [AGE] year-old male that (MDS) dated [DATE] at 1436 with chief complaint of headache for 5 weeks with associated bilateral tinnitus (ringing in ears). Record review revealed documentation the triage nurse assessed the patient at 1454. Review of the triage nurse's assessment revealed no documentation the patient was assessed for pain. Record review revealed the first documented assessment of the patient's pain at 1834, at which time the patient rated the pain 8 out 10 (on a scale of 0 to 10, with 10 being the most intense pain). Record review revealed the patient was given Dilaudid (narcotic analgesic) and Toradol (non steroidal anti-inflammatory medication) via intramuscular injection for pain at 1917. Record review revealed the next available documentation of pain assessment at 2058 (1 hour and 41 minutes after pain medications), at which time the patient rated the pain 4 out of 10. Record review revealed the patient was treated and subsequently discharged to home with a diagnosis of [DIAGNOSES REDACTED]

Interview on 03/20/2012 at 1510 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Further interview on 03/20/2012 at 1600 confirmed there was no available documentation the patient was assessed for pain in triage or within one hour after he received pain medication.

3. Closed medical record review for Patient #7 revealed a [AGE] year-old female that (MDS) dated [DATE] at 1237 with chief complaint of possible seizure. Record review revealed the patient had a history of chronic back pain. Record review revealed documentation the triage nurse assessed the patient at 1242. Review of the triage nurse's assessment revealed no documentation the patient was assessed for pain. Record review revealed the first documented assessment of the patient's pain at 1427, at which time the patient complained of neck pain that she rated 5 out 10 (on a scale of 0 to 10, with 10 being the most intense pain). Record review revealed the patient was treated and subsequently discharged to home with diagnoses of [DIAGNOSES REDACTED]

Interview on 03/20/2012 at 1510 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Interview confirmed there was no available documentation the patient was assessed for pain in triage.

4. Closed medical record review for Patient #6 revealed a [AGE] year-old female that (MDS) dated [DATE] at 1204 with chief complaint of headache for 2 days. Record review revealed documentation the triage nurse assessed the patient at 1227. Review of the triage nurse's assessment revealed no documentation the patient was assessed for pain. Record review revealed the first documented assessment of the patient's pain at 1338, at which time the patient rated her pain 10 out 10 (on a scale of 0 to 10, with 10 being the most intense pain). Record review revealed the patient was treated and subsequently discharged to home with diagnoses of [DIAGNOSES REDACTED]

Interview on 03/20/2012 at 1510 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Further interview on 03/20/2012 at 1600 confirmed there was no available documentation the patient was assessed for pain in triage.






5. Closed medical record review for Patient #15 revealed a [AGE] year-old male that (MDS) dated [DATE] at 1932 with a chief complaint of post procedural fever. Record review revealed documentation the triage nurse assessed the patient at 1938. Review of the triage nurse's assessment revealed no documentation the patient was assessed for pain. Record review revealed the patient was treated and subsequently transferred to another acute care hospital on [DATE] at 0010 with a diagnosis of [DIAGNOSES REDACTED].

Interview on 03/23/2012 at 1430 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Interview confirmed there was no available documentation the patient was assessed for pain during the triage assessment or during the remainder of the ED visit (4 hours and 38 minutes).

6. Closed medical record review for Patient #27 revealed a 6 year-old male that (MDS) dated [DATE] at 2238 accompanied by his mother with a chief complaint of abdominal pain, nausea, vomiting and fever. Record review revealed documentation the triage nurse assessed the patient at 2238. Review of the triage nurse's assessment revealed no documentation the patient was assessed for pain. Record review revealed the patient was given Fentanyl (medication for pain) on 12/26/2011 at 0154. Review of the record revealed the medication was ordered to be given "prn" (as needed) for pain. Review of the record revealed no documentation of an assessment of pain prior to administration of the pain medication, at the time of administration or after administration of the pain medication. Record review revealed the patient was discharged home on 12/26/2011 at 0246. Record review revealed no documentation of a pain assessment during the ED visit (4 hours and 8 minutes).

Interview on 03/21/2012 at 1145 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Further interview on 03/21/2012 at 1140 revealed the manager expected to see Wong-Baker or FLACC assessment tools used for the assessment of pain in pediatric patients. Interview confirmed there was no available documentation the patient was assessed for pain during the triage assessment or during the remainder of the ED visit (4 hours and 8 minutes).

7. Closed medical record review for Patient #10 revealed a [AGE] year-old male that (MDS) dated [DATE] at 2152 with a chief complaint of facial pain due to trauma injury. Record review revealed documentation the triage nurse assessed the patient at 2217. Review of the triage nurse's assessment revealed documentation the patient had a pain level of 9 (scale of 0 - 10, with 10 the worst pain) at 2217. Record review revealed the patient was given Norco (medication for pain) on 03/09/2012 at 0413. Record review revealed no documentation of a pain assessment from 2217 (pain level of 9) through 0413 (5 hours and 56 minutes). Review of the record revealed no documentation of an assessment of pain at the time of administration or after administration of the pain medication. Record review revealed the patient was discharged home on 03/09/2012 at 0422.

Interview on 03/21/2012 at 1145 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Interview confirmed there was no available documentation the patient was assessed for pain after the triage assessment or during the remainder of the ED visit (6 hours and 5 minutes).

8. Closed medical record review for Patient #23 revealed a [AGE] year-old female that (MDS) dated [DATE] at 1745 with a chief complaint of chest pain. Record review revealed documentation the triage nurse assessed the patient at 1753. Review of the triage nurse's assessment revealed documentation the patient had a pain level of 10 (scale of 0 - 10, with 10 the worst pain) at 1753. Record review revealed the patient was given Dilaudid (medication for pain) at 2016 for pain described as a level 10. Record review revealed the patient was discharged home on 03/17/2012 at 2044. Record review revealed no documentation of a pain assessment after the pain medication was administered.

Interview on 03/21/2012 at 1145 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Interview confirmed there was no available documentation the patient was assessed for pain after the pain medication was administered.

9. Closed medical record review for Patient #25 revealed a [AGE] year-old female that (MDS) dated [DATE] at 1522 with a chief complaint of seizure and abdominal pain. Record review revealed documentation the triage nurse assessed the patient at 1525. Review of the triage nurse's assessment revealed documentation the patient had a pain level of 8 (scale of 0 - 10, with 10 the worst pain) at 1525. Record review revealed the patient was discharged home on 03/18/2012 at 1800. Record review revealed no documentation of an assessment of pain after triage or during the remainder of the ED visit (2 hours and 23 minutes).

Interview on 03/21/2012 at 1210 with the ED Nurse Manager revealed all patients should be assessed for pain during the triage assessment. Interview revealed patients should be reassessed for pain during the ED visit based on their condition and within 1 hour of any interventions given for pain. Interview confirmed there was no available documentation the patient was assessed for pain after the triage assessment or during the remainder of the ED visit (2 hours and 23 minutes).