HospitalInspections.org

Based on record review and interview, the hospital failed to ensure a nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by:
1. Failure to assess 3 (FF1, FF5, FF11) of 11 (FF2-FF4, FF6-FF10) patients' response to pain within 30 minutes after IV pain medication;
2. Failure to reassess 1 (FF5) of 11 (FF1-FF4, FF6-FF11) patients' vital signs at a minimum every 2 hours per policy or at time of discharge from emergency department;
3. Failure to document an updated focused assessment on 3 (FF5, FF9, FF11) of 11 (FF1-FF4, FF6-FF8, FF10) patients' per policy.
Findings:

Review of hospital policy revised 01/26/2024 titled "Assessment/Reassessment of Patient in the Emergency Department" revealed in part: POLICY: D. Level 3- urgent will require reassessment every 1-2 hours or as patient condition warrants. H. In addition to recommended assessments based upon ESI triage assessments, reassessments of * Pain reassessment within one hour after administration of oral analgesic, and within 30 minutes of IV analgesic. At time of discharge or transfer, the chart documentation will include as appropriate: Updated focused assessment, including lines, drains, airway (IV, Vitals, Foley, Endotube).


1. Failure to assess 3 (FF1, FF5, FF11) of 11 (FF2-FF4, FF6-FF10) patients' response to pain within 30 minutes after IV pain medication.
Review of Patient FF1 electronic medical record revealed the patient received IV Dilaudid at 1:33 p.m. and had a pain assessment documented as 10/10. The next repeat pain assessment was documented at 3:30 p.m. There was not a pain reassessment within 30 minutes of receiving IV pain medication as per policy.

In an interview on 05/28/2024 at 2:30 p.m. SFF4SDED confirmed the above mentioned findings.

Review of Patient FF5 electronic medical record revealed the patient received 4mg IV Morphine on 05/26/2024 at 8:13 p.m. with a pain assessment documented as 10/10. The patient was discharged home at 12:16 a.m. on 05/27/2024. Further review revealed, there was not a pain reassessment documented on the patient as per policy.

In an interview on 05/28/2024 at 3:39 p.m. SFF4SDED confirmed the above mentioned findings.

Review of Patient FF11 electronic medical record revealed the patient received 4mg IV Morphine on 05/27/2024 at 9:29 p.m. and had a pain assessment documented as 9/10. The next repeat pain assessment was documented at 12:00 a.m. on 05/28/2024. There was not a pain reassessment within 30 minutes of receiving IV pain medication as per policy.

In an interview on 05/29/2024 at 1:25 p.m. SFF4SDED confirmed the above mentioned findings.

2. Failure to reassess 1 (FF5) of 11 (FF1-FF4, FF6-FF11) patients' vital signs at a minimum every 2 hours per policy or at time of discharge from emergency department.
Review of Patient FF5 electronic medical record revealed the last set of vital signs were documented on 05/26/2024 at 5:18 p.m. during triage. This patient was discharge at 12:16 a.m. on 05/27/2024. Further review revealed no reassessment of vital signs within the 2 hour minimum per policy or within 30 minutes of discharge per policy.

In an interview on 05/28/2024 at 3:39 p.m. SFF4SDED confirmed the above mentioned findings.

3. Failure to document an updated focused assessment on 3 (FF5, FF9, FF11) of 11 (FF1-FF4, FF6-FF8, FF10) patients' per policy.
Review of Patient FF5 electronic medical record revealed the patient did not have a focused assessment documented at the time of discharge as per policy.

In an interview on 05/28/2024 at 3:39 p.m. SFF4SDED confirmed the above mentioned findings.

Review of Patient FF9 electronic medical record revealed the patient did not have a focused assessment documented at the time of discharge as per policy.

In an interview on 05/29/2024 at 11:32 a.m. SFF4SDED confirmed the above mentioned findings.

Review of Patient FF11 electronic medical record revealed the patient did not have a focused assessment documented at the time of discharge as per policy.

In an interview on 05/29/2024 at 1:25 p.m. SFF4SDED confirmed the above mentioned findings.