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.
|INDIANA UNIVERSITY HEALTH BALL MEMORIAL HOSPITAL||2401 UNIVERSITY AVE MUNCIE, IN 47303||July 12, 2018|
|VIOLATION: RN SUPERVISION OF NURSING CARE||Tag No: A0395|
|Based upon document review and interview, the Registered Nurse failed to follow hospital policy and evaluate the pain level of each patient arriving to the ED (Emergency Department) for 5 of 10 medical records (MR) reviewed (Patients #1, 3, 4, 7 & 9).
1. Review of the policy/procedure Triage (revised 9-17) indicated the following: "All patients presenting to the [facility] Emergency Department will be triaged by a Registered Nurse (RN)..." and lacked documentation indicating each patient's pain level will be assessed and documented at the time of triage.
2. Review of the policy/procedure Prescribing Opioids for Patients in the Emergency Department (revised 1-18) indicated the following: "Pain will be assessed and documented at triage, after intervention and at discharge."
3. Review of the MR for Patients #1, 3, 4, 7 and 9 lacked documentation indicating the patient's level of pain was assessed and documented by a Registered Nurse at the time of triage.
4. On 7-12-18 at 1310 hours, the Executive Director of Quality, staff A1 and the ED Manager, staff A3 confirmed the MRs for Patients #1, 3, 4, 7 and 9 lacked documentation indicating a pain assessment was performed at the time of triage.