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Based on interview and record review, the hospital failed to ensure the admission assessment was performed for one of five sampled patients (Patient 2) after Patient 2's level of care was changed to the telemetry care level while boarded in the ED. This failure had the potential to result in substandard care for the patient.

Findings:

Review of the hospital's P&P titled Assessment and Documentation dated March 2025 showed the following:

* The admission document criteria should be completed.

* Complete Physical Assessment

- An assessment is done by an RN on admission and will be reassessed throughout the hospital. Assessment is to include consideration of age, psychosocial, environmental, cultural factors and pregnancy status, ability to do self-care, educational needs, and discharge planning factors.

On 5/23/25, Patient 2's open medical record was reviewed. Patient 2's medical record showed Patient 2 arrived at the ED on 5/22/25 at 1733 hours.

Review of the physician's order dated 5/22/25 at 2054 hours, showed to admit Patient 2 to cardiac telemetry level of care.

Review of the ED Provider Notes dated 5/22/25, showed at 2130 hours, based on the patient's condition and test results, the patient will be admitted at this time. At this time, the care of the patient will be transferred to the admitting service.

Review of Patient 2's medical record dated 5/23/25 at 0800 hours, showed Patient 2's head to toe assessment was performed (approximately 11 hours and 30 minutes after the admission order).

On 5/23/25 at 1042 hours, an interview and concurrent review of Patient 2's medical record was conducted with RN 5 in the presence of the Director of Risk Management and Executive Director of Critical Case Services. When asked, RN 5 stated the head-to-toe assessment and admission criteria documentation should be completed within 4 hours of the admission. RN 5 stated the electronic medical record showed the items to be completed under "Admit-Arrival." RN 5 stated the green color next to the items was meaning that it had been completed, and the red color next to the items was meaning that it was incomplete. The incomplete items showed C. Auris Screen, Admit Notification, VS and Pain, Latex Screening, OB Gyn status, Directives, D/C planning, Blood Avoidance, Braden, Skin, Psychosocial, Nutrition, Immunizations, ADL, Care Plan, and Education.

On 5/23/25 at 1330 hours, the Director of Risk Management and Accreditation Program Manager verified the above findings.

Based on interview and record review, the hospital failed to ensure the nursing staff provided the necessary care to two of five sampled patients (Patients 1 and 5) in the ED as evidenced by:

1. The nursing staff failed to administer the pain medication in a timely manner for Patient 1.

2. The nursing staff failed to perform the pain assessment/reassessment as per the hospital's P&P for Patients 1 and 5.

These failures had the potential to result in substandard care to the patients.

Findings:

1. Review of the hospital's P&P titled Medication Administration and Documentation dated March 2025 showed medications shall be administered in a timely manner. Depending on a variety of factors, including but not limited to the pharmacokinetics of the prescribed medication; specific clinical applications; and patient risk factors, medications (unless otherwise noted) shall be administered at scheduled dosing times.

On 5/5/25, Patient 1's closed medical record was reviewed. Patient 1's closed medical record showed Patient 1 arrived in the ED on 5/5/25 at 1358 hours and discharged from the ED at 2103 hours.

Review of the Patient Care Timeline for Patient 1 dated 5/5/25, showed the following:

* At 1429 hours, Patient 1's chief complaint was right flank pain.

* At 1431 hours, Patient 1 complained of pain to the right flank with the pain level of one out of 10 (0 being no pain and 10 being the worst pain).

* At 1641 hours, Patient 1 complained of pain to the right flank with the pain level of eight out of 10.

* At 1915 hours, Patient 1 received morphine (a pain medication) 4 mg IV.

Review of the physician's order for medication dated 5/5/25 at 1519 hours, showed to administer morphine injection 4 mg scheduled on 5/5/25 at 1525 hours. However, Patient 1 received morphine 4 mg at 1915 hours (three hours and 50 minutes later).

On 5/23/25 at 1330 hours, the Director of Risk Management and Accreditation Program Manager verified the above findings.

2. Review of the hospital's P&P titled Pain Assessment and Intervention dated March 2025 showed the following:

* Initial pain assessment includes onset, duration, location(s), quality, intensity, variation and patterns, aggravating/relieving factors, and comfort goal.

* Pain will be reassessed after interventions to evaluate their effectiveness.

a. On 5/5/25, Patient 1's closed medical record was reviewed. Patient 1's medical record showed Patient 1 arrived in the ED on 5/5/25 at 1358 hours and discharged from the ED at 2103 hours.

Review of the Patient Care Timeline for Patient 1 dated 5/5/25, showed the following:

* At 1429 hours, Patient 1's chief complaint was right flank pain.

* At 1431 hours, Patient 1 complained of pain to the right flank with the pain level of one out of 10.
* At 1641 hours, Patient 1 complained of pain to the right flank with the pain level of eight out of 10.

* At 1915 hours, Patient 1 received morphine 4 mg IV.

* At 2045 hours, Patient 1 reported no pain.

However, further review of Patient 1's medical record failed to show a complete pain assessment including onset, duration, quality, variation and patterns, aggravating/relieving factors, and comfort goal as per the hospital's P&P.

On 5/23/25 at 1330 hours, the Director of Risk Management and Accreditation Program Manager verified the above findings.


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b. On 5/5/25, Patient 5's closed medical record was reviewed. Patient 5's medical record showed the patient arrived in the ED on 5/23/25 at 0647 hours and discharged from the ED at 0859 hours.

Review of the Patient Care Timeline for Patient 5 dated 5/23/25, showed the following:

* At 0650 hours, Patient 5's complained of head pain with the pain level of four out of 10.

* At 0656 hours, Patient 5's chief complaint was updated to show head injury without loss of consciousness after a fall.

* At 0857 hours, Patient 5 was assessed by the RN to be in no distress.

However, further review of Patient 5's medical record failed to show complete pain assessment including onset, duration, quality, variation and patterns, aggravating/relieving factors, and comfort goal as per the hospital's P&P.

On 5/23/25 at 1330 hours, the Director of Risk Management and Accreditation Program Manager verified the above findings.