HospitalInspections.org

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Based on a record review and interviews, the facility failed to ensure that all drugs were administered in accordance with Federal and State laws and regulations and the approved medical staff policies and procedures for one of 20 (Patient #1) patients whose medical records were reviewed.
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The Findings were as follows:
Medical Record Review:
There were two Medical Records for Patient #1 provided. One on 02/12/2024 at 1210 PM (16 pages) provided by the Co-Ethics and Compliance Officer, Staff #11. Later, the Chief Administrative Director of Nursing Operations (Staff #2) stated that the record that had been provided was incomplete and provided a second Medical Record for Patient #1 on 02/13/2024 at 2059 pm (21 pages).
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The two Medical Records both showed documentation that a medication, Norco 5/325 mg, was given by Staff #6 on 12/10/2023 at 0246 AM. A reassessment to ensure the effectiveness of the pain medication was not documented in either of the two provided Medical Records for Patient #1 before her discharge on 12/10/2023 at 0255 AM.
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Policy Review:
The Facility's Policy titled, "Pain Assessment & Reassessment", last revised and implemented on 08/2023, stated on page 1:
" ....DEFINITIONS:
1. Pain is a complex, subjective, unpleasant sensory or emotional experience caused by
actual or potential tissue/nerve damage. Medical City Alliance's philosophy is that no
two people experience or express their pain alike and all manifests their own perception
and symptoms in response to pain.
2. Breakthrough pain is severe pain that erupts while a patient is already medicated with a
long-acting pain medication.
3. Pain is defined as the following: Mild - Level 1-3, Moderate - 4-6, Severe - 7-10 on
numeric pain scale."
.
and on page 2:
" .... F. All RN staff will reassess and monitor patients for presence of pain using the 0 - 10
numeric scale, Wong- Baker Pain Scale, Faces, Legs, Activity, Cry, Consolability
(FLACC), Critical Care Pain Observation Tool (CPOT), Neonatal Infant Pain Scale
(NIPS), and/or the Non-Verbal Pain Scale:
1. Pre-operatively
2. Post-operative/post-procedure, as determined by the procedure and severity/intensity of pain
3. At initial assessment per unit protocol
4. With each new report of pain
5. Within one (1) hour after a pain-relieving intervention using one of the approved methods of pain measurement ...."
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Interviews:
In an interview on the afternoon of February 12, 2024, at 1243, Staff #6, the ED Charge RN confirmed that Patient #1 was provided Norco 5/325 mg (documented as administered on 12/10/2023 at 0246 AM) and Patient #1 was discharged on 12/10/2023 at 0255 AM without a reassessment following the documented administration.
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Based on record review, observation, and interview the facility failed to ensure medical records were accurately written in one of 20 records reviewed (Patient #1) when incomplete documentation surrounding the administration of pain medication was noted during medical record and policy reviews.
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The Findings were as follows:
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Medical Record Review:
There were two Medical Records for Patient #1 provided. One on 02/12/2024 at 1210 PM (16 pages) provided by the Co-Ethics and Compliance Officer, Staff #11. Later, the Chief Administrative Director of Nursing Operations (Staff #2) stated that the record that had been provided was incomplete and provided a second Medical Record for Patient #1 on 02/13/2024 at 2059 pm (21 pages). The records did not match. The first Medical Record included nursing's "Rapid Initial Assessment", which is the beginning assessment in Triage. The second Medical Record did not include the "Rapid Initial Assessment." The second Medical Record included "Discharge Instructions" that were not seen in the first Medical Record provided. The first Medical Record provided documented within the "Rapid Initial Assessment" documented a priority level of "2/Emergent" on 12/10/2023 at 0149 AM.
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The total time Patient #1 was in the ED was one hour and seven minutes. The time from arrival on 12/10/2024 at 0148 AM to medical screening assessment on 12/10/2023 at 0151 AM was three minutes. The patient had only one set of vital signs obtained upon her admission on 12/10/2023 at 0149 AM documented a blood pressure of 180/110 (considered "abnormal per Facility Policy), a pulse rate of 118 (considered "abnormal per Facility Policy), and a pain level of 10 (considered "severe" pain per Facility Policy). No follow-up/reassessment of Patient #1's vital signs or pain level could be located in either of the two provided Medical Records for Patient #1.
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The second Medical Record that was provided included nine pages of "Discharge Instructions." The two Medical Records did not include documentation by nursing that discharge instructions were provided to Patient #1. The facility was unable to produce a signed copy of discharge instructions for Patient #1. There was a place for Patient #1 to have signed the instructions, but no signature was observed. The documented discharge time was on 12/10/2023 at 0255 AM.
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Policy Review:
The Facility's policy titled, "Admission and Discharge Criteria", last reviewed and implemented on 08/2022, stated on page 16:
" ....3. Discharge criteria may include:
a. The patient/family/significant other is informed of the diagnosis and offered the
opportunity to ask questions
b. The patient/family/significant other has received appropriate education regarding the patient's injury or illness. Written information/instruction is provided to the patient and may include, but is not limited to:
i. Safe effective use of medication, when applicable
ii. Nutritional information when applicable
iii. Safe and effective use of medical equipment
iv. Signs and symptoms that should be reported
v. Instances when patient should seek immediate help or return to the emergency
room
vi. Suggested time for follow-up care
c. The patient/family/significant other are instructed on the treatment plan
d. Follow-up care is arranged if required ...."
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And on pages 3 - 4:
" ....4. Discharge criteria may include, but not limited to:
b. Stable vital signs
b. Nutrition/hydration adequate for condition, emesis controlled
c. Hematology/chemistry lab values stable
d. Mental status/level of consciousness improving or stable
e. Pain controlled/managed ...."
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The Facility's Policy titled, "Emergency Department Abnormal Vital Signs", last revised and implemented on 12/2023, defined abnormal vital signs on page 2:
" ....Vital sign parameters requiring notification for an adult patient sixteen years old and older:
" Systolic blood pressure less than 90 mmHg or greater than 200 mmHg
" Diastolic blood pressure less than 50 mmHg or greater than 120 mmHg
" Temperature greater than 38.0 Celsius or 100.4 Fahrenheit
" Heart rate of less than 50 bpm or greater than 110 bpm
" Sp02 less than 90% Room Air ...."
.
The Facility's Policy titled, "Triage Assessment and Acuity Level Assignment", last revised and implemented on 12/2023, stated on page 1:
" ....Triage serves to identify life or limb-threatening illnesses/injuries, and patients are prioritized
according to acuity and expected resources needed; according to the Emergency Severity Index
(ESI) 5-Level Triage System. The priorities are categorized as follows:
" Level 1/Resuscitative: Patients presenting in cardiopulmonary arrest/unresponsive
" Level 2/Emergent: Patient is at significant risk and requires multiple resources for
evaluation and treatment, and may have vital signs within a danger zone, as defined by
the ESI 5-Level Triage System ...."
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and on page 3:
" ....Reassessments are performed by an RN periodically to re-evaluate patient condition and symptoms, based upon the patient's initial acuity determination prior to the initiation of the MSE. Reassessment may include vital signs, a focused physical assessment, pain assessment, general appearance, and responses to interventions and treatments. Patient reassessment guidelines are as follows:
" Prior to MSE
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- Level 1/Resuscitative: Every 5-15 minutes, as needed based upon clinical condition
.
- Level 2/Emergent: Every 15 minutes, and based upon clinical condition ....
.
" After MSE
- Level 1/Resuscitative: Every 5-15 minutes, as needed based upon clinical condition. No less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable
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- Level 2/Emergent: At least hourly, based on clinical condition, for a minimum of 4 hours, and more frequently if indicated by clinical condition ...."
.
The Facility's Policy titled, "Pain Assessment & Reassessment", last revised and implemented on 08/2023, stated on page 1:
" ....DEFINITIONS:
1. Pain is a complex, subjective, unpleasant sensory or emotional experience caused by
actual or potential tissue/nerve damage. Medical City Alliance's philosophy is that no
two people experience or express their pain alike and all manifests their own perception
and symptoms in response to pain.
2. Breakthrough pain is severe pain that erupts while a patient is already medicated with a
long-acting pain medication.
3. Pain is defined as the following: Mild - Level 1-3, Moderate - 4-6, Severe - 7-10 on
numeric pain scale."
.
and on page 2:
" .... F. All RN staff will reassess and monitor patients for presence of pain using the 0 - 10
numeric scale, Wong- Baker Pain Scale, Faces, Legs, Activity, Cry, Consolability
(FLACC), Critical Care Pain Observation Tool (CPOT), Neonatal Infant Pain Scale
(NIPS), and/or the Non-Verbal Pain Scale:
1. Pre-operatively
2. Post-operative/post-procedure, as determined by the procedure and severity/intensity of pain
3. At initial assessment per unit protocol
4. With each new report of pain
5. Within one (1) hour after a pain-relieving intervention using one of the
approved methods of pain measurement ...."
.
Interviews:
In an interview on the afternoon of February 12, 2024, at 1243, Staff #6, the ED Charge RN confirmed that Patient #1 was provided Norco 5/325 mg (documented as administered on 12/10/2023 at 0246 AM) and Patient #1 was discharged on 12/10/2023 at 0255 AM without a pain level reassessment following the documented administration.
.
In an interview on the afternoon of February 12, 2024, at 1228 PM and on February 13, 2024, at 0816 AM, Staff #5, the treating ED Physician, confirmed that Patient #1 did not receive stabilization and monitoring of an elevated blood pressure per the Facility's policy.
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In an interview on the morning of February 13, 2024, at 1126, Staff #8, the Facility's ED Medical Director, it was confirmed that Patient #1 did not have blood pressure monitoring per the Facility's Policy, that the Facility could not accurately confirm that Patient #1 had received discharge instructions, and that stabilization of Patient #1's emergency medical condition had not occurred before being discharged. The ED Medical Director also confirmed that the current discharge policy and process were insufficient.
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In an interview on the afternoon of February 12, 2024, at approximately 1300 pm, Staff #2, the Director of Nursing Operations, it was confirmed that the Facility could not accurately confirm had received discharge instructions, It was also confirmed that the current discharge policy and process were insufficient.
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Patient #1 also alleged that she was not provided discharge instructions. Patient #1 provided a screenshot following the incident of Patient #1's "myhealthone" patient portal was provided that was taken on 12/10/2023 at 0531 AM, which was 2 hours and 36 minutes following her discharge. The screenshot shows:
"Discharge Summaries.
You have no discharge instructions on file."
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Based on observation, record review, and interview, the Facility failed to provide an appropriate discharge for one of 20 (Patient #1) by discharging Patient #1 without ensuring that Patient #1's health had improved sufficiently so the patient no longer needed care.
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The Findings Included:
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Medical Record Review:
There were two Medical Records for Patient #1 provided. One on 02/12/2024 at 1210 PM (16 pages) provided by the Co-Ethics and Compliance Officer, Staff #11. Later, the Chief Administrative Director of Nursing Operations (Staff #2) stated that the record that had been provided was incomplete and provided a second Medical Record for Patient #1 on 02/13/2024 at 2059 pm (21 pages). The records did not completely match. The first Medical Record included nursing's "Rapid Initial Assessment", which is the beginning assessment in Triage. The second Medical Record did not include the "Rapid Initial Assessment." The second Medical Record included "Discharge Instructions" that were not seen in the first Medical Record provided. The first Medical Record provided documented within the "Rapid Initial Assessment" documented a priority level of "2/Emergent" on 12/10/2023 at 0149 AM. There was no documented change made to Patient #1's priority level.
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The total time Patient #1 was in the ED was one hour and seven minutes. The time from arrival on 12/10/2024 at 0148 AM to medical screening assessment on 12/10/2023 at 0151 AM was three minutes. The patient had only one set of vital signs obtained upon her admission on 12/10/2023 at 0149 AM documented a blood pressure of 180/110 (considered "abnormal per Facility Policy), a pulse rate of 118(considered "abnormal per Facility Policy), and a pain level of 10 (considered "severe" pain per Facility Policy). No follow-up/reassessment of Patient #1's vital signs or pain level was located in either of the two provided Medical Records for Patient #1.
.
Policy Review:
The Facility's policy titled, "Admission and Discharge Criteria", last reviewed and implemented on 08/2022, stated on page 16:
" ....3. Discharge criteria may include:
a. The patient/family/significant other is informed of the diagnosis and offered the
opportunity to ask questions
b. The patient/family/significant other has received appropriate education regarding the patient's injury or illness. Written information/instruction is provided to the patient and may include, but is not limited to:
i. Safe effective use of medication, when applicable
ii. Nutritional information when applicable
iii. Safe and effective use of medical equipment
iv. Signs and symptoms that should be reported
v. Instances when patient should seek immediate help or return to the emergency room
vi. Suggested time for follow-up care
c. The patient/family/significant other are instructed on the treatment plan
d. Follow-up care is arranged if required ...."
.
And on pages 3 - 4:
" ....4. Discharge criteria may include, but not limited to:
a. Stable vital signs
b. Nutrition/hydration adequate for condition, emesis controlled
c. Hematology/chemistry lab values stable
d. Mental status/level of consciousness improving or stable
e. Pain controlled/managed ...."
.
The Facility's Policy titled, "Emergency Department Abnormal Vital Signs", last revised and implemented on 12/2023, defined abnormal vital signs on page 2:
.
" ....Vital sign parameters requiring notification for an adult patient sixteen years old and older:
-Systolic blood pressure less than 90 mmHg or greater than 200 mmHg
-Diastolic blood pressure less than 50 mmHg or greater than 120 mmHg
-Temperature greater than 38.0 Celsius or 100.4 Fahrenheit
-Heart rate of less than 50 bpm or greater than 110 bpm
-Sp02 less than 90% Room Air ...."
.
The Facility's Policy titled, "Triage Assessment and Acuity Level Assignment", last revised and implemented on 12/2023, stated on page 1:
" ....Triage serves to identify life or limb-threatening illnesses/injuries, and patients are prioritized
according to acuity and expected resources needed; according to the Emergency Severity Index
(ESI) 5-Level Triage System. The priorities are categorized as follows:
.
-Level 1/Resuscitative: Patients presenting in cardiopulmonary arrest/unresponsive
.
-Level 2/Emergent: Patient is at significant risk and requires multiple resources for
evaluation and treatment, and may have vital signs within a danger zone, as defined by
the ESI 5-Level Triage System ...."
.
and on page 3:
" ....Reassessments are performed by an RN periodically to re-evaluate patient condition and symptoms, based upon the patient's initial acuity determination prior to the initiation of the MSE. Reassessment may include vital signs, a focused physical assessment, pain assessment, general appearance, and responses to interventions and treatments. Patient reassessment guidelines are as follows:
.
-Prior to MSE
.
-Level 1/Resuscitative: Every 5-15 minutes, as needed based upon clinical condition
.
- Level 2/Emergent: Every 15 minutes, and based upon clinical condition ....

-After MSE
.
-Level 1/Resuscitative: Every 5-15 minutes, as needed based upon clinical condition. No less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable
.
-Level 2/Emergent: At least hourly, based on clinical condition, for a minimum of 4 hours, and more frequently if indicated by clinical condition ...."
.
The Facility's Policy titled, "Pain Assessment & Reassessment", last revised and implemented on 08/2023, stated on page 1:
" ....DEFINITIONS:
1. Pain is a complex, subjective, unpleasant sensory or emotional experience caused by
actual or potential tissue/nerve damage. Medical City Alliance's philosophy is that no
two people experience or express their pain alike and all manifests their own perception
and symptoms in response to pain.
2. Breakthrough pain is severe pain that erupts while a patient is already medicated with a
long-acting pain medication.
3. Pain is defined as the following: Mild - Level 1-3, Moderate - 4-6, Severe - 7-10 on
numeric pain scale."
.
and on page 2:
" .... F. All RN staff will reassess and monitor patients for presence of pain using the 0 - 10
numeric scale, Wong- Baker Pain Scale, Faces, Legs, Activity, Cry, Consolability
(FLACC), Critical Care Pain Observation Tool (CPOT), Neonatal Infant Pain Scale
(NIPS), and/or the Non-Verbal Pain Scale:
1. Pre-operatively
2. Post-operative/post-procedure, as determined by the procedure and severity/intensity of pain
3. At initial assessment per unit protocol
4. With each new report of pain
5. Within one (1) hour after a pain-relieving intervention using one of the approved
methods of pain measurement ...."
.
Interviews:
In an interview on the afternoon of February 12, 2024, at 1243, Staff #6, the ED Charge RN confirmed that Patient #1 was provided Norco 5/325 mg (documented as administered on 12/10/2023 at 0246 AM) and Patient #1 was discharged on 12/10/2023 at 0255 AM without a reassessment following the documented administration.
.
In an interview on the afternoon of February 12, 2024, at 1228 PM and on February 13, 2024, at 0816 AM, Staff #5, the treating ED Physician, confirmed that Patient #1 did not receive appropriate monitoring of an elevated blood pressure per the Facility's policy.
.
In an interview on the morning of February 13, 2024, at 1126, Staff #8, the Facility's ED Medical Director, it was confirmed that Patient #1 did not have blood pressure monitoring per the Facility's Policy, that the Facility could not accurately confirm that Patient #1 had received discharge instructions before being discharged. It was also confirmed that the current discharge policy and process were insufficient.
.
In an interview on the afternoon of February 12, 2024, at approximately 1300 pm, Staff #2, the Director of Nursing Operations, confirmed that the Facility could not accurately confirm that Patient #1 had received discharge instructions. It was also confirmed that the current discharge policy and process were insufficient.
.
Patient #1 also alleged that she was not provided discharge instructions. Patient #1 provided a screenshot following the incident of Patient #1's "myhealthone" patient portal was provided that was taken on 12/10/2023 at 0531 AM, which was 2 hours and 36 minutes following her discharge. The screenshot shows:
"Discharge Summaries.
You have no discharge instructions on file."
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Patient #1 maintains that she had such a violent reaction following ingestion of the Norco, which was taken in combination with her prescribed Ambien, that it would have been impossible and unsafe to have driven home had that been the case.
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Based on interview and record review, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements when they did not provide an appropriate medical screening exam (MSE) for one out of 20 patients (Patient #1).

On 12/10/2023, Patient #1 presented to the emergency department with complaints of leg and hip pain. Medical records show that Patient #1 was provided with an MSE at 0151, given pain medication at 0252, and was discharged from the ED at 0255 without an acknowledgement of discharge instructions. There were no documented follow-ups to the patient's status which included follow-up pain assessments or reassessments of patient vitals. Furthermore, the physical exam did not include documentation of any evaluation of the back or leg, which was Patient #1's primary concern.

Cross reference to Tag A2406 CFR §489.24(c).
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Based on medical record reviews, facility documentation reviews, and interviews, the facility failed to:
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1. Perform and document an appropriate medical screening examination (MSE) in 1 of 20 patient records reviewed (Patient #1).
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2. Follow its policies regarding medical screening examinations, stabilization, admission and discharge criteria, vital sign assessments and reassessments, physical examination assessments and reassessments, and pain assessments and reassessments in 1 of 20 patient records reviewed (Patient #1).
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The Findings Included:

Medical Record Review:
A Medical Record for Patient #1 on 02/12/2024 at 1210 PM (16 pages) was provided by the Co-Ethics and Compliance Officer, Staff #11. The Chief Administrative Director of Nursing Operations (Staff #2) stated that the record that had been provided was incomplete and provided a second Medical Record for Patient #1 on 02/13/2024 at 2059 pm (21 pages).
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The first medical record noted on 12/10/2023 at 0149 AM by Staff #10 (an emergency department registered nurse), "Patients description or reason for visit:
C/O (complaints of) sudden left leg pain starting from hip to left knee x 1 week . ... no fall or trauma. Called telehealth and was advised to come to ER .... prescribed Etodolac 1 week ago."
The Medical Record also notes a chief complaint of "joint pain" of the left hip on 12/10/2023 at 0158 AM and a documented pain at a level "10" on 12/10/2023 at 0204 AM.
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Patient #1 had one set of vital signs obtained upon her admission/presentation on 12/10/2023 at 0149 AM. The documented blood pressure was 180/110, a pulse rate of 118, and a pain level of 10, which are abnormal findings. No follow-up/reassessment of Patient #1's vital signs was documented before discharge on 12/10/2023 at 0255 AM in the provided Medical Records for Patient #1. There were no follow-up pain assessments or reassessments documented in for Patient #1.
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In the second medical record, there are no nursing notes and no triage notes. The record shows on 12/10/2023 at 0155 AM, the reason for the visit was "1 week of left thigh pain ...not relieved by Toradol" per Staff #5's (the treating ED Provider) History and Physical. This record does not mention a pain level.
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The two Medical Records both showed documentation that a medication, Norco 5/325 mg, was documented as given by Staff #6 on 12/10/2023 at 0246 AM. A reassessment to ensure the effectiveness of the pain medication was not documented in either of the two provided Medical Records for Patient #1.
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No further appropriate history regarding the patient symptoms was found. The physical exam does not include any evaluation of the back or leg and there is no focal neurologic exam to evaluate for neurologic referred pain to the leg. There were no reassessments documented in one of the 20 patients whose medical records were reviewed (Patient #1).
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Policy Review:
The Facility's policy titled, "Admission and Discharge Criteria", last reviewed and implemented on 08/2022, stated on page 16:
" ....3. Discharge criteria may include:
a. The patient/family/significant other is informed of the diagnosis and offered the opportunity to ask questions
b. The patient/family/significant other has received appropriate education regarding the patient's injury or illness. Written information/instruction is provided to the patient and may include, but is not limited to:
i. Safe effective use of medication, when applicable
ii. Nutritional information when applicable
iii. Safe and effective use of medical equipment
iv. Signs and symptoms that should be reported
v. Instances when patient should seek immediate help or return to the emergency room
vi. Suggested time for follow-up care
c. The patient/family/significant other are instructed on the treatment plan
d. Follow-up care is arranged if required ...."
.
And on pages 3 - 4:
" ....4. Discharge criteria may include, but not limited to:
c. Stable vital signs
b. Nutrition/hydration adequate for condition, emesis controlled
c. Hematology/chemistry lab values stable
d. Mental status/level of consciousness improving or stable
e. Pain controlled/managed ...."
.
The Facility's Policy titled, "Emergency Department Abnormal Vital Signs", last revised and implemented on 12/2023, defined abnormal vital signs on page 2:
" ....Vital sign parameters requiring notification for an adult patient sixteen years old and older:
Systolic blood pressure less than 90 mmHg or greater than 200 mmHg
Diastolic blood pressure less than 50 mmHg or greater than 120 mmHg
Temperature greater than 38.0 Celsius or 100.4 Fahrenheit
Heart rate of less than 50 bpm or greater than 110 bpm
Sp02 less than 90% Room Air ...."
.
The Facility's Policy titled, "Triage Assessment and Acuity Level Assignment", last revised and implemented on 12/2023, stated on page 1:
" ....Triage serves to identify life or limb-threatening illnesses/injuries, and patients are prioritized according to acuity and expected resources needed; according to the Emergency Severity Index (ESI) 5-Level Triage System. The priorities are categorized as follows:
Level 1/Resuscitative: Patients presenting in cardiopulmonary arrest/unresponsive
Level 2/Emergent: Patient is at significant risk and requires multiple resources for evaluation and treatment, and may have vital signs within a danger zone, as defined by the ESI 5-Level Triage System ...."
.
and on page 3:
" ....Reassessments are performed by an RN periodically to re-evaluate patient condition and symptoms, based upon the patient's initial acuity determination prior to the initiation of the MSE. Reassessment may include vital signs, a focused physical assessment, pain assessment, general appearance, and responses to interventions and treatments. Patient reassessment guidelines are as follows:
.
Prior to MSE
.
Level 1/Resuscitative: Every 5-15 minutes, as needed based upon clinical condition
.
Level 2/Emergent: Every 15 minutes, and based upon clinical condition ....
.
After MSE
Level 1/Resuscitative: Every 5-15 minutes, as needed based upon clinical condition. No less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable
.
Level 2/Emergent: At least hourly, based on clinical condition, for a minimum of 4 hours, and more frequently if indicated by clinical condition ...."
.
The Facility's Policy titled, "EMTALA- Medical Screening Examination and Stabilization Policy", last revised and implemented on 11/20/2023, stated on page 12:
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" .... a. Stable. The physician or QMP providing the medical screening and treating the emergency has determined within reasonable clinical confidence, that the EMC that caused the individual to seek care in the DED has been resolved although the underlying medical condition may persist ...."
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and on page 13:
" .... c. Stabilizing Treatment and Individuals Whose EMCs Are Resolved. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his or her continued care, .... The EMC that caused the individual to present to the DED must be resolved, but the underlying medical condition may persist. Hospitals are expected within reason to assist/provide discharged individuals the necessary information to secure follow-up care to prevent relapse or worsening of the medical condition upon release from the hospital ...."
.
The Facility's Policy titled, "Pain Assessment & Reassessment", last revised and implemented on 08/2023, stated on page 1:
" ....DEFINITIONS:
1. Pain is a complex, subjective, unpleasant sensory or emotional experience caused by actual or potential tissue/nerve damage. Medical City Alliance's philosophy is that no two people experience or express their pain alike and all manifests their own perception and symptoms in response to pain.
2. Breakthrough pain is severe pain that erupts while a patient is already medicated with a long-acting pain medication.
3. Pain is defined as the following: Mild - Level 1-3, Moderate - 4-6, Severe - 7-10 on numeric pain scale."
.
and on page 2:
" .... F. All RN staff will reassess and monitor patients for presence of pain using the 0 - 10 numeric scale, Wong- Baker Pain Scale, Faces, Legs, Activity, Cry, Consolability (FLACC), Critical Care Pain Observation Tool (CPOT), Neonatal Infant Pain Scale (NIPS), and/or the Non-Verbal Pain Scale:
1. Pre-operatively
2. Post-operative/post-procedure, as determined by the procedure and severity/intensity of pain
3. At initial assessment per unit protocol
4. With each new report of pain
5. Within one (1) hour after a pain-relieving intervention using one of the approved methods of pain measurement ...."
.
Interviews:
In an interview on the afternoon of February 12, 2024, at 1243, Staff #6, the ED Charge RN confirmed that Patient #1 was provided Norco 5/325 mg (documented as administered on 12/10/2023 at 0246 AM) and Patient #1 was discharged on 12/10/2023 at 0255 AM without a pain level reassessment following the documented administration.
.
In an interview on the afternoon of February 12, 2024, at 1228 PM and on February 13, 2024, at 0816 AM, Staff #5, the treating ED Physician, confirmed that Patient #1 did not receive stabilization and monitoring of an elevated blood pressure per the Facility's policy.
.
In an interview on the morning of February 13, 2024, at 1126, Staff #8, the Facility's ED Medical Director, confirmed that Patient #1 did not have blood pressure monitoring per the Facility's Policy, that the Facility could not accurately confirm that Patient #1 had received discharge instructions, and that stabilization of Patient #1's emergency medical condition had not occurred before being discharged. The ED Medical Director also confirmed that the current discharge policy and process were insufficient.
.