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MONUMENT HEALTH RAPID CITY HOSPITAL 353 FAIRMONT BLVD POST OFFICE BOX 6000 RAPID CITY, SD 57701 Aug. 18, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on review of the Hospital's Emergency Department (ED) logs, review of medical records, policy review, and staff interviews, it was determined the Hospital failed to comply with the provider agreement as defined in 489.20 and 489.24. Findings include:

a. The Hospital failed to provide a medical screening examination that was, within reasonable clinical confidence, sufficient to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 20 sampled (13) ED patients. See A2406, finding A1 and A2, for patient specifics.

b. The Hospital failed to ensure nursing staff completed ongoing comprehensive pain assessments and documented effectiveness of administered pain medications for 6 of 20 sampled (1, 2, 8, 11, 15, and 16) ED patients. See A2406, findings B1, B2, B3, B4, B5, and B6 for patient specifics.
VIOLATION: MEDICAL SCREENING EXAM Tag No: A2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on interview and medical record review, the Hospital failed to provide a medical screening examination that was, within reasonable clinical confidence, sufficient to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 20 sampled (13) ED patients. Findings include:

1. Review of patient 13's ED record dated 5/19/14 revealed she had presented to the ED at 3:05 a.m. and was seen by the physician at 3:15 a.m. for complaints of abdominal pain and vomiting.

Review of patient 13's ED record revealed the following physician orders had been documented:
*At 3:20 a.m.:
-A urine and pregnancy test.
-Intravenous (IV) normal saline.
-IV morphine 4 milligrams (mg) for pain.
-Zofran 4 mg for nausea.
-Tylenol 1 gram.
*At 4:32 a.m. Toradol 30 mg for pain.
*At 5:00 a.m.:
-Zofran 4 mg.
-Discharge home.
*At 5:02 a.m. a physician order cancelling the urine and pregnancy test.

Review of the nursing exam [examination] on 5/19/14 at 3:30 a.m. revealed the patient had complained of nausea and vomiting since 2:00 a.m. that morning, had left lower abdomen pain that increased with palpation, and had vomited four times since 2:00 a.m.

Review of patient 13's ED history and physical (H&P) report dated 5/19/14 and timed 3:30 a.m. revealed:
*She had awaken about 2:00 a.m. from sleep due to abdominal pain. On Saturday [5/17/14], she had nausea, vomiting, and abdominal pain; and on Sunday [5/18/14], she had felt better.
The patient's symptoms were intermittent, now moderate in severity; at rest, nothing caused an increase in symptoms and nothing relieved the symptoms.
*Her abdomen had normal bowel sounds and was soft and tender.
*She denied having [DIAGNOSES REDACTED]
*Reevaluation of the patient at 4:31 a.m. the patient was feeling improved after medication administration, was now able to provide a urine specimen, and would wait for test results.
*At 5:04 a.m. she had not been able to provide a urine specimen and there were no complaints of hematuria (blood in the urine) or dysuria (painful urination).
*The physician documented "I doubt she has urinary tract infection and likely her abdominal pain is gastritis given her recent vomiting and abdominal pain."
*She had been discharged in stable condition with instructions to follow-up with her primary physician within 7-10 days.

Review of the laboratory test results for 5/19/14 at 3:25 a.m. revealed:
*White blood cells WBC) were high at 19.5, normal range was 4.0 - 10.5. An elevated WBC was an indicator for an infection in the body.
*[DIAGNOSES REDACTED] were high at 83 percent (%), normal range was 30 - 50%.
*Lymphocytes were low at 5%, normal range was 25 - 33%.
*Sodium level was low at 133 millimole (mmol)/Liter (L), normal range was 137 - 149 mmol/L
*Glucose (blood sugar) was high at 158, normal range being 70 - 110 mg/deciliter.

Review of the 5/19/14 ED visit for 3:05 a.m. revealed no radiological testing (abdominal/pelvic x-ray or computerized tomography [CT] scan or ultrasound testing of the patient's abdomen had been completed.

Review of patient 13's vital signs and pain documentation on 5/19/14 revealed:
*3:11 a.m. - Temperature was 100.8 degrees Fahrenheit (F), pulse 126, respiratory rate (RR) 33, blood pressure (B/P) 159/80, O2 oxygen saturation (O2 Sat) 94 percent (%) room air [percent of oxygen in the blood], and "Just a pain lower abd [abdomen]."
*4:00 a.m. - Pulse was 116 and O2 Sat 96%. A pain assessment had not been documented.
*5:09 a.m. - At the time of discharge - Pulse was 109, RR 17, B/P 11/55, and O2 Sat 94%. On a numeric scale she had rated her pain 2 out of 10 (pain scale 0 no pain and 10 worst pain). The location of the pain had not been documented.

Review of patient 13's medication administration record on 5/19/14 revealed:
*Zofran 4 mg had been administered by mouth at 3:26 a.m. with documentation of improvement at 4:36 a.m.
*Morphine 4 mg by IV had been administered at 3:38 a.m. with documentation of improvement at 4:36.
*Tylenol 1 gram had been administered at 4:35 a.m. with documentation of improvement at 4:36 a.m.
*Ketorolac 30 mg by IV had been administered at 4:35 a.m. with documentation of improvement at 5:08 a.m.
*The registered nurses had not documented a reason for the administration of the above medications.

Review of patient 13's discharge documentation on 5/19/14 at 5:08 a.m. revealed the patient had been discharged home with discharge instructions and a take home pack of Zofran.

Interview on 8/13/14 at 11:55 a.m. with ED physician A who provided care to patient 13 revealed he had based his medical decision making on the patient's presenting symptoms and had treated her for gastritis. ED physician A stated after the patient had received pain medications, anti-nausea medications, and intravenous fluids she had felt better. Her pain was a 2 out of 10 (pain scale 0 no pain and 10 worst pain) at the time of her discharge home.

Interview on 8/14/14 at 11:10 a.m. with the ED medical director revealed:
*He had not completed a formal review of the patient's medical record. He had reviewed the operative report on the patient when she returned later that same day (5/19/14). In accordance with the size of the abscess, it might have been discovered with an abdominal x-ray or CT scan. The medical director stated due to the size of the abscess around the appendix it had started several days ago, not just within the hours of her first ED visit until the second one on 5/19/14.

2. Review of patient 13's ED record on 5/19/14 revealed this was the patient's second ED visit within 24 hours for complaints of abdominal pain. Patient 13 had been seen in the Hospital's ED earlier that morning at 3:05 a.m. and was discharged home at 5:08 a.m. Specific patient information of the 5/19/14 ED visit at 3:00 a.m. can be found at A2406, finding 1.

Review of patient 13's second ED medical record for 5/19/14 revealed:
*She had presented to the Hospital's ED at 5:10 p.m. with complaints of abdominal pain.
*She had been evaluated by the physician at 6:57 p.m.
*The physician had ordered at 7:00 p.m.:
-IV normal saline, IV Zofran 4 mg, and IV morphine 10 mg.
-Abdominal/pelvic CT scan with IV contrast (dye for better visualization) for right lower quadrant abdominal pain, nausea, and vomiting.
-Rectal temperature, blood cultures times two if febrile (fever), and nothing by mouth.

Review of patient 13's ED history and physical report dated 5/19/14 revealed:
*Her abdominal pain had worsened. She had pain with movement or coughing, and nausea and vomiting for the past several days.
*She had no diarrhea, had fevers and growing malaise (sense of not feeling well).
*She had been seen last night in the ED, was treated symptomatically, was not eating, and had a WBC of 19,000.
*Her condition had not improved after she had been discharged home from the ED earlier that day (5/19/14 at 5:08 a.m.), she had gone to a local urgent care, and had been referred to the hospital for an emergency specialist evaluation.
*IV fluids, pain medications, and anti-nausea mediations had been administered.
*Clinical examination findings were discussed with a general surgeon who recommended an abdominal CT scan. The CT scan had confirmed acute appendicitis with possible perforation.
*diagnoses included [DIAGNOSES REDACTED]
*The patient was admitted to the operating room in critical condition for emergency surgical intervention.

Review of patient 13's CT of the abdomen and pelvis with contrast report dated 5/19/14 at 7:34 p.m. revealed:
*The appendix was "markedly abnormal."
*A diagnose of "Acute appendicitis, with significant inflammatory change surrounding the appendix, right colon and a small amount of free fluid extending into the pelvis."
*An abscess had not been identified.

Review of the physician B's surgical consultant history and physical electronically signed 6/20/14 revealed the patient abdomen was "Tender in the right lower quadrant over McBurney's point. She has a positive Rovsing sign [positive sign for appendicitis] with voluntary guarding and rebound." The CT scan indicated appendix inflammatory changes without evidence of perforation. Physician B had documented a diagnose of acute appendicitis and recommended a laparoscopic appendectomy.





B. The Hospital failed to ensure nursing staff completed ongoing comprehensive pain assessments and documented effectiveness of administered pain medications for 6 of 20 sampled (1, 2, 8, 11, 15, and 16) ED patients. Findings include:

1. Review of patient 15's ED medical record revealed:
*On 6/29/14 at 1:58 p.m. she presented to the ED with complaints of abdominal pain that had started two months ago.
*At 2:11 p.m. the RN documented the patient had sharp right-sided pain that radiated into her back. The patient had rated her pain a 7 out of 10.
*At 3:25 p.m. the RN administered IV Morphine, there was no documented pain location.
*At 4:47 p.m. the RN documented "improved," approximately 1 hour and 22 minutes later.

Interview on 8/13/14 at 1:35 p.m. with the ED director revealed the RN's assessment of the patient's response to the IV Morphine should have been done sooner.

2. Review of patient 16's medical record revealed:
*On 6/27/14 at 1:07 p.m. he had presented to the ED after hitting his head two days ago with complaints of a fever, neck pain, and abdominal pain.
*At 1:13 p.m. the RN documented the patient had head, arm, and stomach pain. The patient had rated his pain a 10 out of 10.
*At 2:55 p.m. the RN administered ibuprofen 200 mg and Tylenol 400 mg. There was no documented pain location.

3. Review of patient 2's medical record revealed:
*The patient (MDS) dated [DATE] at 2:47 a.m. with right lower quadrant abdominal pain.
*The patient's pain level was assessed as a 7 out of 10 at 3:01 a.m.
*The patient was started on a saline IV lock at 3:27 a.m.
*The patient's vital signs were taken at 4:30 a.m., but the pain assessment was not documented.
*The physician noted at 4:37 a.m. the patient was in minimal if any distress and the symptoms were not consistent with appendicitis.
*The patient was discharged at 6:30 a.m. with no further pain assessments documented.

Interview on 8/13/14 at 1:35 p.m. with the ED director revealed:
*The pain assessment's for patient 2 had not met the emergency department's protocol.
*He would have expected a pain assessment at the time of the patient's discharge.

4. Review of patient 8's medical record revealed:
*The patient (MDS) dated [DATE] at 6:27 p.m. with abdominal pain, a previous history of a left ovarian cyst, and a headache.
*The pain assessment of 5 out of 10 was documented at 6:32 p.m.
*The patient was given Toradol at 7:51 p.m. and hydrocodone at 7:52 p.m. for pain.
*The patient's response to the Toradol and hydrocodone was not documented.
*The pain assessment was not documented at the time of the patient's discharge.
*The patient was discharged at 8:30 p.m.

Interview on 8/13/14 at 1:35 p.m. with the ED director revealed he would have expected the patient's response to pain medication and the patient's discharge vital signs to have been documented.

5. Review of patient 1's medical record revealed:
*The patient (MDS) dated [DATE] at 1:45 a.m. with abdominal pain and suspicion of bilateral kidney stones.
*The patient's pain level was assessed at the following times:
-1:46 a.m. (8 out of 10).
-2:46 a.m. (9 out of 10).
-4:52 a.m. (7 out of 10).
-6:56 a.m. (4 out of 10).
*Nurse's note at 2:46 a.m. that said "Patient states pain getting worse."
*Nurse's note at 3:18 a.m. stating "has not been seen by physician yet."
*There was no documentation of the physician having been notified of the patient's pain levels prior to the patient being seen.
*Patient was seen by the physician at 4:13 a.m.
*The patient was given Morphine 9 mg at 4:37 a.m. and Toradol 30 mg at 4:51 a.m.
*The patient was discharged at 7:05 a.m. with no documented pain assessment.

Interview on 8/13/14 at 1:35 p.m. with the ED director revealed he would have liked the patient to have been sooner by the physician based on the patient's pain levels.

6. Review of the provider's March 2014 Identification of the Need for Pain Management policy revealed:
*"Upon arrival to the Emergency Department, patients will be triaged by a Registered Nurse and the triage questionnaire completed. This questionnaire will include information relating to the patients pain level, quality and location.
*A specific pain rating will be noted. A 0-10 scale or the Wong Baker Face scale will be utilized as appropriate.
*Patients with ongoing pain or pain greater than 4/10 [4 out of 10] will have pain issues addressed per hospital policy."

Review of the provider's November 2013 Pain Management policy revealed:
*The pain assessment should have documented the intensity, location, quality, and duration of the patient's pain.
*Patients with pain ratings of 7 to 10 correspond with severe pain.
*The frequency of pain assessment varied by department and as clinically indicated.
*"Interventions are indicated and expected for pain which is unacceptable to the patient, often a pain scale rating greater than 4 on a 0-10 pain scale."

Review of the provider's March 2014 Medication Administration policy revealed:
*The nurse or a paramedic was responsible for assessing the patient after the administration of the first dose of any new medication.
*"During and after the administration of any medication, staff caring for patients will monitor the response to the medication, observing and documenting the therapeutic effects of the medication or any adverse drug reactions."

Interview on 8/13/14 at 1:35 p.m. and on 3:10 p.m. and on 8/14/14 at 7:55 a.m. with the ED director revealed:
*Patients would not be given pain medication or have IV's started until seen by a physician even if it took two hours.
*Patients should be "rounded" by the nurses every hour. "Rounding" could be asking the patient if they needed anything or if their condition had changed.
*Vital signs should be taken every two hours.
*Pain was one of the vital signs, so it should have been addressed.
*Pain assessment should include the quality and the location of the pain on the initial assessment and reassessments.
*Response to pain medication should be assessed an hour after administration. Response could be written or checked on the medical record box matching the patient's response.
*The provider's policy for patient's assessments was based on input from the ED medical director.

Interview on 8/14/14 at 11:10 a.m. with the ED medical director revealed:
*"Rounding" on patients should occur at a minimum of every hour.
*Nurses performed patient's vital signs as clinically necessary. At a minimum they should have been done at the time of the patient's admission and discharge.
*He would expect his staff to document the patient's response to medication administration.