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MEMORIAL MISSION HOSPITAL AND ASHEVILLE SURGERY CE 509 BILTMORE AVE ASHEVILLE, NC 28801 Sept. 20, 2019
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 reviews and staff interviews, the facility staff failed to manage pain in 1 of 8 Emergency Department (ED) records reviewed (Patient #4).

The findings included:

Review on 09/17/2019 of a policy titled "Pain Assessment and Management", last revised on April 22, 2019, revealed PURPOSE: The purpose of this policy is to provide guidelines for assessment and management of pain patients served by HCA Mission Health. ...POLICY: A. Each patient is screened for the presence of pain in all settings where treatment is provided...B...The frequency of pain assessment is based on patient symptoms, interventions, and progress towards goals...D...Prevention of severe pain has been shown to improve healing. Therefore proactive pain management may be preferred to reactive pain treatment, particularly in patients experiencing severe and/or predictable pain..." The policy did not address any requirements for the frequency of pain assessments or documentation of a patients pain before medication administration..

Emergency Department (ED) record review for Patient #4, on 09/17/2019, revealed the [AGE] year old male arrived to the ED via private vehicle on 08/07/2019 at 0701. Review of the ED record revealed Patient #4 was triaged by RN #1 at 0702 and self reported a pain score of 1 out of 10. Review revealed RN #2 performed a Nursing Assessment at 0720 and did not reassess Patient #4's pain at that time. Review of Patient #4's MSE (Medical Screening Exam) revealed it was initiated at 0833 (1 hour and 32 minutes after Patient #4's arrival to the ED) by Family Nurse Practitioner (FNP) #1. Review of the ER Report revealed Patient #4 had a history of tortuous left ureter and was found to have intrarenal stones in the past. The review revealed Patient #4 had a ureteoscopy a few months prior and the stones could not pass through the ureter due to the tortuosity of the ureter. Review further revealed Patient #4 had developed some severe left flank pain overnight and thought he was constipated. Patient #4's Physical Exam revealed "General: Initially the patient appeared to be quite uncomfortable...Gastrointestinal: ...The patient is very tender in the left lower quadrant/flank region...Psychiatric: As mentioned the patient was quite uncomfortable initially. This actually created some agitation in him." The FNP note revealed Hydromorphone (pain medication) 0.5 mg IV push and Ondansetron (nausea medication) 4 mg IV push were both ordered at 0820. Review of the MAR (Medication Administration Record) revealed, RN #2 administered the ordered medications at 0838. Record review revealed Patient #4 reported a pain score of 10 at the time of the medication administration

Review of the Staffing Sheets for 08/07/2019, revealed two medical doctors were available to evaluate patients prior to 0800 when FNP #1 arrived.

Interview with the ED Director on 09/18/2019 at 1610 revealed the ED had at least 2 Pods (areas in the ED) with an MD available 24 hours per day. Interview revealed if a patient was roomed in a pod (area) without a medical provider until 0800 and started having pain they could be seen by a provider in another pod. The nurse, interview revealed, could just walk right over to the other pod and request orders be placed until the provider in that pod arrived."

Interview with RN #2 on 09/19/2019 at 1020 revealed she was the Primary RN for Patient #4. Interview revealed "He thought he was constipated, but also had a history of left sided kidney stones." Interview revealed, "If it's the patient I'm thinking of, he was in pain." Interview further revealed the provider in the adjacent pod typically sees the patients in that pod until their provider arrives. "A lot of the time they know who's waiting to be seen by looking at the tracking board." RN #2 revealed that on this morning, her co-worker, RN #3, actually walked over to notify the provider that Patient #4 was in pain and requesting pain medicine. "I did not follow-up or attempt to notify the provider myself." Interview revealed RN #2 remembered Patient #4 asked to go to another facility because he was in pain and there was no provider in that pod, RN #2 stated, "I tried to discourage him. I recall the patient wanted to go to Urgent Care, but I knew he would just end up getting sent back here." RN #2 stated that she would normally notify the provider if pain was an issue and acknowledged that she did not in this case. Review revealed RN #2 documented pain assessments on admission and again only if there is a change or after an intervention. RN #2 recalled charting a pain assessment at the time of medication administration. Interview revealed Patient #4 did not have pain medicine ordered until after FNP #1 arrived. RN #2 was unable to recall if Patient #4 ever communicated he was in pain to anyone else later that afternoon. RN #2 stated the nurses do carry phones, but if the staff answering the call bell did not see the nurse right away, and were busy with other tasks, there could be a delay in communication. Interview revealed it is common to hear the pain score directly from the patient, not from the person answering the call bell.

Interview with RN #3 on 09/19/2019 at 1127, revealed RN #3 remembered Patient #4 and assisted RN #2 by walking over to the Pod to notify the doctor of Patient #4's pain. "I don't recall exactly the situation, but I feel like the provider was caught up in a situation." RN #3 stated she did not follow-up because she was not the primary nurse and was just "helping out."

Interview with RN #4 on 09/20/2019 at 1013, revealed "I've been in (Patient #4's Pod) with no provider before and and I've gone over to the provider in (Pod name) because the providers in (adjacent Pod name) are usually pretty busy."

Interview with the ED Nurse Manager on 09/20/2019 at 1132, revealed there is no policy on documenting at the time a patient requests pain medicine or makes the nurse aware they have pain. Interview revealed it is usually documented at the time of medication administration. Interview revealed, there is place in the EMR (Electronic Medical Record) where staff should be documenting when a provider is notified about any patient condition or change. "It is my expectation that nurses follow the policy around pain assessments and reassessments. I do not remember the exact wording in the policy because it's been changed several times."

Interview requested on 09/19/2019 and 09/20/2019 revealed MD #1 was not available.

NC 712, NC 000, NC 498, NC 145