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.

CHRISTUS GOOD SHEPHERD MEDICAL CENTER- LONGVIEW 700 EAST MARSHALL AVENUE LONGVIEW, TX 75601 April 17, 2017
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure nursing staff provided on-going and complete evaluations on 3 of 13 sampled patients presenting to the Emergency Department (ED) (Patient #'s 1, 8, and 11).

This deficient practice had the likelihood to cause harm in all patients presenting to the Emergency Department (ED).


Findings include



Review of the clinical record of Patient #11 revealed he was a [AGE] year old male who (MDS) dated [DATE] at 6:37 p.m.. Patient #11 presented with complaints of "CHEST PAIN THAT STARTED 3 HOURS PTA WITH COLD SWEATS."

Nursing staff triaged Patient #11 at 6:39 p.m. and documented under the pain section "The patient complains of pain in the chest." There was no other documentation underneath the area.

Nursing failed to complete the pain assessment. Vital signs were taken but the area for the pain level was left blank.

At this time, nursing gave Patient #11 an acuity level of 2 (Emergent).

Review of the medication administration section revealed Patient #11 was given some of the following medications:

At 6:52 p.m., 6:58 p.m. and 7:03 p.m. the vasodilator agent Nitroglycerin;

The next set of vital signs was taken after the third dose of Nitroglycerin. There was no documentation of assessment of how the medication was affecting the patient's vital signs on the first two doses and there was no documentation of what the pain level was to justify the administration of three doses of Nitroglycerin.

At 7:39 p.m., the pain agent Morphine was given and at 8:26 p.m. the pain agent Dilaudid was given.

The last documented vital signs were at 7:44 p.m. There was no documentation of what the pain level was to justify the administration of the Morphine.

At 8:34 p.m., Patient #11 was admitted into the cardiac unit. At this time, nursing documented Patient #11 had a pain level of 5 out of 10. Over 2 hours after presenting to the ED this was the first documentation of a pain level.




Review of the clinical record of Patient #8 revealed she was a [AGE] year old female who (MDS) dated [DATE] at 9:17 p.m.

Review of the triage assessment at 10:07 p.m. revealed Patient #8 presented with complaints of "BACK PAIN". Vital signs were taken and the pain level was listed as being 10 out of 10 (0 indicated no pain and 10 indicated severe pain).

Review of the triage assessment revealed the following documentation, "Patient home medication information was provided by the: patient."

There was no documentation of Patient #8's home medications on the assessment.

Review of the pain assessment section revealed the following documentation;
"Pain: The patient complains of pain in back. The patient describes the current level of pain as 10/10."
There was no other documentation underneath the section.

Patient #8 was given an acuity level at this time of 4 (meaning Semi-urgent). This was not the correct acuity level for severe pain.

According to the medication administration record Patient #8 was given the anti-anxiety agent Valium and pain medication Tylenol#3 at 11:40 p.m. (over 2 hours after presenting to the ED).

There was no documentation of what the pain level was or vital signs to justify the administration of the medication.

At 12:03am, Patient #8 was discharged and staff documented the pain level was 3 out 10. There still no documentation of vital signs prior to discharge.



Review of the clinical record of Patient #1 revealed she was a [AGE] year old female who presented to the Emergency department (ED) on 08/08/2016 at 11:12 a.m. Patient #1 presented with "pain in left lower quadrant."

Review of the triage assessment at 11:16 a.m., revealed Patient #1 "Reports pain in right lower quadrant(s)."

Review of the triage assessment revealed the following documentation "Patient home medication information was provided by the: patient."

There was no documentation of Patient #1's home medications on the assessment.

At 11:19 a.m., Patient #1 was assessed as having acuity level of 3 (meaning urgent). Nursing documented that Patient #1 had a pain level of 8 out of 10 (0 indicated no pain and 10 indicated severe pain). This was not the correct acuity level for severe pain.

There was documentation that Patient #1 left the hospital at 1:47 p.m. and there was no documentation of treatment being provided.

Review of another clinical record on Patient #1 revealed she returned on 08/09/2016 at 1:08 p.m.

At 1:24 p.m. there was documentation that Patient #1 had a pain level of 10 out of 10. According to the physician's documentation Patient #1 was diagnosed with a urinary tract infection, syncope and drug seeking behavior. The records revealed administration of intravenous fluids and an intravenous antibiotic.


During an interview on 04/17/2017 after 10:00 a.m., Staff #6 confirmed the missing assessments.


Review of the facility policy named "Emergency Triage Protocol" effective date 02/2011 revealed the following:

" ...3. The triage protocol defines patient conditions into five categories. The following examples are used as guidelines and are to be assigned in conjunction with good clinical judgement. These five categories are defined as follows:
a. ESI (Emergency severity index) Level 1; Resuscitation-Requires immediate life-saving intervention.
b. ESI Level 2; Emergent-High -risk situation or confused/lethargic/disoriented or severe pain/distress.
c. ESI Level 3; Urgent - (Examples) closed fracture, laceration/contusions, sprains, non cardiac chest pains how many resources are needed? Many? Consider vitals and upgrading to level 2 if vitals are unstable.
d. ESI Level 4; Semi-Urgent- How many different resources are needed? one
e. ESI Level 5; Non-Urgent How many resource are required? None ..."

Review of the facility's policy titled "Pain Management" dated 09/12/2016 revealed the following:

...2. An age and ability-appropriate comprehensive assessment should be conducted for any patient reporting or suspected of having pain.
a. The comprehensive assessment should include, to the extent relevant, the patient's impression as to the intensity of the pain, site(s) quality (e.g. dull, sharp, throbbing, stabbing), radiation, onset (e.g. when did the pain start, is it increasing or decreasing), functioning (e.g. dose the pain keep your from performing certain? functions?), and sleep (e.g. does the pain interfere with your sleep? Rest?)."

..5. Severe vs. Non-Severe Pain: The nurse should use their judgement to integrate the data collected (e.g. the patient's self-reported pain level, objective external signs of severe pain) to assess whether the patient's level of pain appears to be severe. Objective external signs of severe pain include but are not limited to grimacing, guarding, crying, increased respiratory and/or heart rate, and diaphoresis."