HospitalInspections.org

Based on facility policy review, medical record review, and staff interviews, the facility failed to provide patient assessments and reassessments of vital signs and pain per facility policies in 5 of 23 patient records sampled (Patient #'s 22, 6, 8, 14, 21).

The findings included:

Review on 03/07/2024 of the facility policy "DRH ED Documentation Policy Emergency Department Nursing ID:8245," revised 09/01/2023, "... Procedure: A. Basic Triage Documentation - Adult ... g. Vital signs will include temperature noting modality, heart rate, respiration rate, blood pressure and pain level h. Pulse oximetry when appropriate ... C. Documentation of Triage Status Re-Checks of Waiting Patients a. Vital signs, observations, and patient condition updates are to be performed at a minimum ... based on initial ESI level as follows: i. ESI Level 2-every 2 hours ii. ESI Level 3-every 3 hours iii. ESI Level 4, 5-Every 4 hours ... D. Documentation of Ongoing Assessments While in Patient Treatment Area ... a ... vii. Vital signs, observations, and patient condition updates are to be performed based on initial ESI level as follows: 1. ESI Level 1-every 15 minutes until condition stabilizes, then every hour 2. ESI Level 2-every 2 hours 3. ESI Level 3-every 3 hours 4. ESI Level 4, 5-every 4 hours ... E. Documentation of Discharged Patients (Treated and Released) a. Vital signs including pain level within last hour ... I. Documentation for Patients Requiring a Psychiatric Evaluation ... h. Vital signs every 6 hours or more frequently based on patient clinical status ... J. Documentation for Admissions Holding Patient ... b ... iii. Vital signs every 4 hours ..."

Review on 03/07/2024 of the hospital policy "DUHS Pain Management Policy" ID 2330, revised 11/18/2020, "... Procedure: A. Initial Assessment: (see sections L. & M. for ambulatory and ED requirements) ... M. Emergency Department Nursing- 1. Pain Assessment and Documentation a. ... all patients will be screened for the presence/absence of pain at that time of presentation for care or with any new complaint of pain by patient/family or caregiver. b. Pain will be initially assessed at time of triage and both pharmaceutical and non-pharmacologic interventions, if administered, to address pain will be documented in the patient EMR. c. Reassessment of pain will occur within one hour as required following any pain intervention."

1. Closed medical record review completed 03/06/2024 revealed Patient #22 (Pt#22) a 44-year-old presented to the Emergency Department (ED) on 12/09/2023 at 1023 with altered mental status and a headache at the back base of the head and was assigned a patient acuity score (ESI) of 2 (reflects the urgency of care with 1 being the greatest need and 5 being the least). The Patient Care Timeline revealed the initial triage vital signs at 1024 as temperature 36.6, heart rate 85, respiratory rate 18, blood pressure 154/82, and a room air pulse ox of 97%. There was no pain assessment documented. The Patient Care Timeline revealed on 12/09/2023 at 1152 Pt#22 was medicated with Toradol (non-narcotic pain medication) 15mg (milligrams) and Zofran (antinausea medicine) 4mg IV (intravenous) for pain and nausea. There was no reassessment of pain within one hour of medication administration. At 1402 a pain scale of 2/10 (0/10 is no pain and 10/10 is the worst pain) was documented on the Patient Care Timeline. The next set of vital signs documented on 12/09/2023 at 1820 revealed a temperature of 36.8, heart rate 86, respiratory rate 19, and blood pressure 139/78, and room air pulse ox of 97%. Vital signs at 1848 were documented as temperature 36.7, heart rate 77, blood pressure 149/78, and a room air pulse ox of 96%. Vital signs documented at 2042 revealed a heart rate of 84, blood pressure 141/82, and a room air pulse ox of 95%. There was no temperature or respiratory rate documented. A pain assessment was documented at 2045 revealing a rating of 5/10 and Pt#22 was given Motrin (non-narcotic pain medicine) 400mg orally. There was no reassessment of pain completed within one hour of the medication administration. The Patient Care Timeline revealed Pt#22 was admitted to observation status on 12/10/23 at 0052. A final set of vital signs was documented at 0848 and revealed temperature 36.7, blood pressure 133/84, heart rate 79, respiratory rate of 16, and room air pulse ox of 96% with the discharge diagnosis of acute encephalopathy. The medical record review failed to reveal a complete set of initial vital signs according to facility policy. Record review failed to reveal a pain assessment with pharmacological intervention and a follow-up reassessment within one hour of medication administration. Record review failed to reveal ongoing documentation of vital signs according to ESI level or according to the holding guidelines.

Interview on 03/07/2024 at 1715 with the Clinical Director (CD#2) revealed the expectation for staff to follow written policy. CD#2 revealed that vital signs should be completed as per policy and a pain assessment should be completed upon arrival, a reassessment after medication administration, and based upon policy as it relates to the patient acuity score.

2. Closed medical record review completed 03/06/2024 revealed Patient #6 (Pt#6) a 65-year-old presented to the Emergency Department (ED) on 08/09/2023 at 1224 via ambulance with complaints of altered mental status and assigned a patient acuity score (ESI) of 3 (reflects the urgency of care with 1 being the greatest need and 5 being the least). The Patient Care Timeline revealed that the initial triage vital signs completed at 1226 were temperature 36.6, heart rate 98, respiratory rate 18, blood pressure 125/87, pulse ox 98% on room air, and pain rated 0/10 (0/10 is no pain and 10/10 is the worst pain). At 1444 the Patient Care Timeline revealed temperature of 36.6, heart rate 98, respiratory rate 18, blood pressure 125/87. Pt#6 was discharged at 2157 with a final diagnosis of altered mental status and seizure with no other vital signs recorded. During Pt#6's hospitalization, staff failed to provide vital signs according to ESI and within one hour of discharge.

Interview on 03/07/2024 at 1715 with the Clinical Director (CD#2) revealed the expectation for staff to follow written policy. CD#2 revealed that vital signs should be completed as per policy and a pain assessment should be completed upon arrival and based upon policy as it relates to the patient acuity score. CD#2 revealed that vital signs should be completed within one hour of discharge.

3. Closed medical record review completed 03/06/2024 revealed Patient #8 (Pt#8) a 33-year-old presented to the Emergency Department (ED) on 02/24/2024 at 0738 with complaints of needing a psychiatric evaluation with a history of drinking, doing drugs, and hearing voices and assigned a patient acuity score (ESI) of 2 (reflects the urgency of care with 1 being the greatest need and 5 being the least). The Patient Care Timeline revealed the initial triage vital signs from 0753 as temperature 36.7, heart rate 93, respiratory rate 18, blood pressure 118/63, and pulse ox 98% on room air. There was no pain assessment documented. Pt#8 was then discharged at 1629 with no other vital signs documented. During Pt#8's hospitalization, staff failed to provide complete vital signs and pain assessments according to the psychiatric hold guidelines in the documentation policy.

Interview on 03/06/2024 at approximately 1000 with the Assistant Chief Nurse of Psychiatry revealed that the expectation was that nurses followed the documentation policy related to vital signs for psychiatric evaluation as well as upon discharge from the facility.

Interview on 03/07/2024 at 1715 with the Clinical Director (CD#2) revealed the expectation for staff to follow written policy. CD#2 revealed that vital signs should be completed as per policy, including a pain assessment upon arrival and within one hour of discharge.




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4. Closed medical record review completed on 03/06/2024 revealed Patient #14 (Pt#14), a 44-year-old female, presented to the Emergency Department (ED) on 01/13/2024 at 1803 with a chief complaint of back and abdominal pain. Medical record review revealed Pt#14 presented to triage on 01/13/2024 at 1809 and was assigned an ESI level of 3. Triage vital signs at 1809 were temperature 36.9, heart rate 102 (normal heart rate range is 60-100), respirations 16, blood pressure 162/125 (high blood pressure is considered 140/90 or higher), a pulse oximetry level 97% on room air and a pain level 6/10. Record review revealed that Pt#14 received 0.5 milligrams of intravenous Dilaudid for pain level 8/10 (0/10 is no pain and 10/10 is the worst pain) at 1925. Review failed to reveal a reassessment of pain within one hour after Dilaudid was administered. At 2117, P#14 was medicated with a second dose of 0.5 milligrams intravenous Dilaudid with no documented pain assessment or reassessment within one hour after administration. Review revealed Pt#14 was discharged at 2252 on 01/13/2024. Review failed to reveal vital signs within one hour of discharge.

Interview with a Clinical Director (CD#2) on 03/07/2024 at 1715 revealed that staff was expected to follow written policy for documentation of vital signs and pain assessment. Interview revealed policy was not followed for documentation of vital signs and pain assessment for Pt#14.

5. Closed medical record review completed on 03/06/2024 revealed Patient #21 (Pt#21), a 37-year-old female, presented to the Emergency Department (ED) on 01/10/2024 at 1023 with a chief complaint of back pain. Medical record review revealed Pt#21 presented to triage on 01/10/2024 at 1037 and was assigned an ESI level of 4. Triage vital signs at 1039 were temperature 37, heart rate 70, respirations 16, blood pressure 133/79 and pulse oximetry level 100% on room air. Review revealed Pt#21 was given 15 milligrams of intravenous Toradol at 1149 and 0.5 milligrams of intravenous Dilaudid at 1150 with no documented pain assessment. Review failed to reveal a reassessment of pain within one hour after Toradol and Dilaudid were administered. Pt#21 was discharged on 01/10/2024 at 1611. Review failed to reveal vital signs and pain assessment within one hour of discharge.

Interview with a Clinical Director (CD#2) on 03/07/2024 at 1715 revealed that staff was expected to follow written policy for documentation of vital signs and pain assessment. Interview revealed policy was not followed for documentation of vital signs and pain assessment for Pt#21.