HospitalInspections.org

Based on chart reviews, interviews, policy , and procedure reviews the facility failed to ensure patients were informed of services by providing signed consents in 2 (#1 and #5) of 5 (#1-5) patient charts reviewed.
Review of patient #1's chart revealed the consent for "Baptist Hospitals of Southeast Texas Authorization for the use of Protected Health Information", and "Informed Consent for Intravenous Contrast Media (CT)" was signed by patient #1. The following consents had "unable to sign" written in the patient signature line;
1. Joint notice of privacy practices acknowledgment.
2. Accident information and coordination of benefits.
3. Patient rights and responsibilities.
4. Consents/Authorizations/Disclosures.
A telephone interview with patient #1 on 4/22/14 revealed that he signed all paperwork that was offered to him. Patient #1 stated, "I was never unable to sign any paperwork." Patient #1 denied having any confusion or altered mental status upon arrival to the hospital.
Review of patient #5's chart revealed a "Informed Consent for Intravenous Contrast Media (CT)" form. review of the form revealed the word "verbal" on the patient consent signature line. Staff #15 signed as the only witness to the patients' verbal consent. The patient was able to sign all other consents upon ED arrival. There was no documentation to describe why the patient was unable to sign. There was no other staff signature to witness the verbal consent.
Review of the policy and procedure, "Safe Administration Of Intravenous Contrast" revealed, "In the event that the patient cannot give informed consent, or cannot complete the contrast consent form, the next of kin or the person who had Medical Power of Attorney will be required to fill the form out before the administration of contrast."

Based on record reviews and interview, the facility failed to follow its own policy and procedures for nursing assessment and pain assessment in 4 (#1, 2, 3,and 5) of 5 (#1-5) charts reviewed. This deficient practice had the likelihood to effect all patients experiencing pain.
Review of facility policy titled "Emergency Department Assessments and Documentation" revealed the triage assessment is performed by a registered nurse and data will include;
"#5. Assessment of chief complaint- including pain level assessment on scale of 1-10.
#6. Vital signs: B/P, T, P, R, weight, height, and SaO2.
B. Primary Nursing Assessment;
* V/S and reassessment of pain scale will be obtained again before discharge.
* Interventions and chief complaint will be reassessed periodically."

Review of patient #1's chart revealed patient #1 was seen by the triage nurse in the emergency department (ED) with abdominal pain on 12/21/13 at 8:45 AM. The Emergency Nursing Record had a section for "pain level." The "pain level" was blank.
Review of the Physician Record revealed a severity pain level of "sever"(sic) was written for patient #1. There was no scale to the pain level documented. The physician documented that the patient had a history of Gastritis, Diabetes, and Gout.
Review of the Physician Order Sheet revealed the following orders;
1. Normal Saline 1000 ml(milliliters) was ordered to be given IV bolus (A large volume of fluid given intravenously and rapidly at one time.)
2. A Urinary Analysis, blood work, IV, abdominal and pelvis CAT scan with oral contrast.
3. Morphine 10 mg slow intravenous push (SIVP). Two lines were drawn through the 10 mg. with 5 mg. written below the lined through 10 mg., with the physician signature.
4. " Transfer to S.C. Med center. Medical floor obs. "
There was no date or time documented for any of the above orders.
Review of the Emergency Nursing Record revealed the following;
1. Patient #1 had no nursing documentation of a pain assessment at arrival, during treatment, or at transfer.
2. There was no nursing documentation of Morphine 5mg. given to patient #1 for pain. The nurse failed to follow physician orders.
3. There was no nursing documentation on the amount of Normal Saline infused through the IV.
4. There was no nursing documentation of vital signs taken after triage, during treatment, or discharge. There was no nursing documentation that the patient was stable at the time of the transfer.
5. There was no nursing documentation that the IV was discontinued or the condition of the IV site upon transfer.
6. There was no signature of the discharging nurse.
7. Additional notes written on the Emergency Nursing Record had initials after the comments. There were no names or disciplines documented after each entry.
Review of facility policy titled "Emergency Department Assessments and Documentation" revealed;
"F. Interventions;
* All nursing interventions including the time performed and the initials of the nurse performing the procedure will be documented.
1. List all medications given including the time, name of the drug, dose, route, site and signature.
2. Document the response to all medications given.
3. List all IV solutions hung specifying the time, name of the solution, amount hung, site and rate of solution.
G. Disposition;
* Upon discharge a final pain scale and set of vital signs will be obtained."

Review of the Emergency Nursing Record revealed patient #1 arrived in the ED at 8:45 AM and departed at 9:00 PM a total of 12 hours and 15 minutes. Patient #1's blood sugar reading of 164 was documented at 8:45 AM. At 4:00 PM a blood sugar entry of 85 was noted. There was no documentation that the patient was offered any food or fluids by mouth. There was no further documentation of monitoring or testing the patient for signs or symptoms of hyper/hypoglycemia. There was no documentation that patient #1 was NPO (nothing by mouth) or that the patient was instructed not to eat or drink.
An interview with staff #2, 5, 6, and 9 on 4/15/2014 confirmed the above findings.
An interview was conducted with staff #9 on 4/15/14. Staff #9 reported patient #1 was initially her patient. Staff #9 reported that patient #1 was in pain and the pain assessment was not documented. Staff #9 reported that another patient she was caring for became more acute and required her attention. Staff #9 confirmed staff #11 was assisting with patient #1 and had documented on the patient #1's chart. Staff #9 confirmed there was no documentation that the Morphine 5 mg. was administered. Staff #9 stated, "He probably didn't get the care he should have." Staff #9 denied any staffing issues.
An interview with patient #1 was conducted on 4/22/14. Patient #1 confirmed there was no pain medication administered in the ED. Patient #1 stated, "I have very low blood sugar at times and was never offered anything to eat. I was never told I could not have anything to eat. When my blood sugar dropped down in the 80's they gave me some grape juice. I told them I was getting tired of using my hand as a cup to get water out of the sink".
B. Review of patient #5's chart revealed patient #5 was seen by the triage nurse in the emergency department (ED) with abdominal pain on 12/21/13 at 10:20 PM. The Emergency Nursing Record had a section for " pain level." The "pain level" revealed a 6 out of 10 pain level.
Review of the Physician Order Sheet revealed an order for the following;
1. Demerol (analgesic) 25 mg and Zofran (antiemetic) 4 mg slow IVP.
2. Normal Saline 1000 ml bolus then 100 ml/ per hour.
3. Blood work and a urinalysis.
4. Abdominal and pelvis CAT scan with IV contrast.
There was no date or time documented for any of the above orders.
Review of the Emergency Nursing Record revealed patient #5 received the Demerol and Zofran at 12:25 AM. There was no reassessment of pain or effectiveness of pain medication or antiemetic during the ED visit or at discharge. There was no nursing documentation on the amount of Normal Saline infused through the IV. There was no nursing documentation that the IV was discontinued at discharge.
Review of the Informed Consent for Intravenous Contrast Media (CT) form had the word "verbal" on the patient consent signature line. Staff #15 signed as the only witness to the patients' verbal consent. The patient was able to sign all other consents upon ED arrival. There was no documentation to describe why the patient was unable to sign.
Review of the policy and procedure titled "Safe Administration Of Intravenous Contrast" revealed, "In the event that the patient cannot give informed consent, or cannot complete the contrast consent form, the next of kin or the person who had Medical Power of Attorney will be required to fill the form out before the administration of contrast."
C. Review of patient #3's chart revealed patient #3 was seen by the triage nurse in the emergency department (ED) with Regurgitation on 12/22/13 at 2:36 PM. Review of the Emergency Nursing Record and the Emergency Physician Record had no documentation or assessment of pain.
D. Review of patient #2's chart revealed patient #2 was seen by the triage nurse in the emergency department (ED) with right Testicular swelling and groin pain on 12/22/13 at 11:55 AM. Review of the Emergency Physician record revealed pain level as moderate.
Review of the Physician Orders revealed Rocephin (antibiotic) 250 mg IM was ordered with no documentation of date or time. There was no pain medication ordered.
Review of the Emergency Nursing Record revealed that the patient reported a pain level of 8 out of 10 at 11:55 AM. when triage was conducted. Patient #2 was taken to a patient room at 1:40 PM. and no time documented for when the physician saw the patient. The ER record revealed the nursing assessment and the physician record had no documentation of pain assessment. There was no further pain assessment performed during the ED visit or when patient was discharged at 5:30 PM (over 5 hours later).

Based on chart reviews and interviews the facility failed to ensure physician orders were timed and dated on 3 (#1, 5, and 2) out of 5 (#1-5) patient charts reviewed.
Review of patient #1's Physician Order Sheet revealed the following orders;
1. Normal Saline 1000 milliliters was ordered to be given bolus (A large volume of fluid given intravenously and rapidly at one time.)
2. A Urinary Analysis, blood work, IV, abdominal and pelvis CAT scan with oral contrast.
3. Morphine 10 mg slow intravenous push (IVP). Two lines were drawn through the 10 mg. and 5 mg was written below the lined through 10mg, with the physician signature.
4. " Transfer to S.C. Med center. Medical floor obs." There were no dates or times documented for any of the above orders.
Review of patient #5's Physician Order Sheet revealed an order for the following;
1. Demerol (analgesic) 25 mg and Zofran (antiemetic) 4 mg slow IVP.
2. Normal Saline 1000 ml bolus then 100 ml/ per hour.
3. Blood work and a urinalysis.
4. Abdominal and pelvis CAT scan with IV contrast. There were no dates or times documented for any of the above orders.
Review of Patient #2's Physician Orders revealed Rocephin (antibiotic) 250 mg IM was ordered with no documentation of date or time.
An interview with staff #2, 5, 6, and 9 on 4/15/2014 confirmed patient #1's physician orders were not dated or timed.