Upland Hills Health

“RECORDS SYSTEM CFR(s): All orders of doctors of medicine or osteopathy or other practitioners, reports of treatments and medications, nursing notes and documentation of complications, and other pertinent information necessary to monitor the patient’s progress, such as temperature graphics, progress notes describing the patient’s response to treatment; and This Standard is not met as evidenced by: 29972 Based on record review and interview the facility staff failed to document Emergency Department (ED) nursing assessments, monitoring, and evaluations addressing patient care needs and response to treatments in 10 of 10 ED medical records reviewed (Patient (Pt) #1, 2, 3, 4, 5, 6, 7, 8, 9, 10), in a total sample of 10 ED records reviewed. Findings Include: Review of “Pain Care Management Protocols” origination date October 15, 2001 revealed the following: -“All patients are assessed on admission for the presence of pain.” -“Pain is assessed using a tool appropriate to the patient’s age and ability and documented in the medical record...Cognitive adults...are asked to rate their pain using the Numeric Rating Scale (NRS) (Numbers 0-10).” -“Assess the patient’s pain by using a pain assessment tool or scale or by asking key questions and noting the patients’ response to pain.” -“Acute...patients who are receiving pharmacological pain therapy are reassessed within one hour of each intervention.” -“Evaluate your patient’s response to pain management. If the patient is still in pain, reassess...and alter care plan as appropriate.” -“Pain assessment, reassessment and the pain scale used is documented in the patient’s medical record...Documentation should include the administration of medication and any other interventions...” Review of the facility’s Emergency Secondary Assessment guidelines from “Elsevier Clinical Skills” copyright 2023 revealed the following: - “Full Set of Vital Signs...Obtain and trend readings for blood pressure (BP), pulse, respiratory rate (RR), peripheral oxygen saturation (Sp02) and temperature at regular intervals.” -“Continue ongoing monitoring and evaluation of the patient. Reevaluation should include the primary survey (complaint), vital signs, level of pain, and any injuries identified.” -“Perform a focused assessment of any injuries or abnormalities found.” -“Evaluate the patient’s evolving condition by monitoring these indicators and intervene as needed...Neurological status, Vital Signs...Assess, treat, and reassess pain...” -“Documentation: Vital signs...Injuries and conditions found in the secondary assessment...mechanism of injury or history of present illness...Interventions performed...Patient’s response to interventions...Education.” Review of policy and procedure #ER 5.2 titled, “Discharge and Instructions” last date reviewed 07/2008 revealed the following: -Vital signs are obtained immediately prior to decision to discharge for patient with high risk clinical presentations (i.e. any patient that presented with abnormal vital signs, trauma, chest pain, and new onset headaches)...Abnormal vitals are defined as: 8 years or older...Heart Rate >100...RR >20...Sp02 <92%. -“Pre-discharge re-evaluations include clinically pertinent assessment of the presenting complaint.” Pt #1: Review of Pt #1’s medical record revealed Pt #1 arrived to the ED on 07/10/2023 at 5:57 AM with an Arrival Complaint revealing, “Reported headache, neck and back pain with chills, vomiting in triage, thinks had fever, started out with ear ache yesterday then developed headache.” Pt #1 was discharged home from the ED on 07/10/2023 at 10:45 AM. Review of Pt #1’s ED Physician G’s Provider Notes dated 07/10/2023 at 7:24 AM revealed, “(Pt #1)...is a 59 year old...presented to the emergency department with a headache that has been present for the past 2 days. No recent falls, accidents, or injuries...Nausea with several episodes of vomiting but (Pt #1) denies abdominal pain or diarrhea...No neurological changes or deficits, no changes in vision or speech...(Pt #1) denies a history of headaches but admits she has been in the ER (emergency room) many times for headaches...The light is bothering her eyes due to the headache...” Review of Pt #1’s Physician G’s Physical Exam dated 07/10/2023 revealed that Pt #1 was “Ill-appearing” and was “uncomfortable but able to answer most questions appropriately.” Per ED G’s physical exam, Pt #1 was “...alert and oriented to person, place, and time. (Pt #1) is not disoriented”; “Patient is cooperative despite discomfort throughout ED visit.” Review of Pt #1’s ED timeline of care on 07/10/2023 revealed the following: -6:19 AM: Given Toradol (treatment for Migraines). -6:20 AM: Given Benadryl (treatment for Migraines). -6:25 AM: Given Reglan (treatment for vomiting). -6:23 AM: Given Dexamethasone (treatment for Migraines). -7:00 AM: Registered Nurse (RN) C documented, “Patient stated no relief, MD (medical doctor) made aware.” -7:11 AM: Given Droperidol (treatment for Migraines). -7:35 AM: RN C documented, “(Pt #1) Stated no change with pain, MD updated.” -8:05 AM: Given Ativan (anti-anxiety medication). -8:13 AM: Patient hyperventilating and rolling in bed, sheets and pillow with call light on floor. MD made aware.” -8:18 AM, Radiologist’s Head CT (computed tomography) findings revealed, “The ventricles are of normal size, shape, and contour for the patient’s age. The brainstem, cerebellum, and cerebral hemispheres have a normal morphology and CT attenuation. There is no evidence of midline displacement. No hemorrhage, mass effect, mass lesions, or edema is evident.” -9:03 AM: RN C documented, “Tried calling mother for patient for ride home.” -9:47 AM: RN C documented, “...patient refusing to get off the floor, rolling around, refusing discharge instructions and to leave the ER” -10:45 AM: Patient discharged to home. Review of Pt #1’s ED Triage/Nursing Notes from 07/10/2023 at 5:57 AM to 10:55 AM revealed there was no documentation of a focused nursing assessment/evaluation (i.e. Neurological and Gastrointestinal) addressing Pt #1’s complaints of a headache, nausea/vomiting. Review of the nurses notes revealed there was no documentation of a nursing re-evaluation of Pt #1’s response to treatment (Reglan at 6:25 AM), addressing Pt #1’s nausea and vomiting. Review of Pt #1’s ED Triage/Nursing notes from 07/10/2023 at 5:57 AM to 10:55 AM revealed there was no documentation of nursing staff completing pain assessments and re-assessments using a Numerical Rating Scale as per policy. Review of Pt #1’s ED Triage/Nursing notes from 07/10/2023 at 8:05 AM to 10:55 AM (after giving Ativan) revealed there was no documentation of a nursing re-evaluation of Pt #1’s response to treatment, addressing Pt #1 hyperventilating and rolling around on the floor. Pt #1 was discharged home at 10:45 AM. Review of Pt #1’s Vital signs (VSs) log dated 07/10/2023 at 6:04 AM revealed Pt #1’s temperature was 95.7 (98.6 normal) and the RR was 32 (>20 abnormal as per policy); Pt #1’s RR was re-checked at 7:17 AM and was 30. Review of Pt #1’s VSs log from 7:19 AM through 10:45 AM (3 hours 26 minutes later) revealed there was no documentation of staff rechecking Pt #1’s abnormal temperature and RR, and obtaining a full set of vital signs (BP, pulse, RR, temperature, Sp02) prior to Pt #1’s discharge (10:45 AM) as per policy. Pt #2: Review of Pt #2’s ED medical record revealed Pt #2 arrived in the ED on 07/28/2023 at 11:06 PM with a chief complaint of abdominal pain. Review of Pt #2’s ED medical record revealed there was no documentation of a BP, a pain assessment, and a focused nursing assessment (i.e. Gastrointestinal & Genitourinary) addressing Pt #2’s complaint of abdominal pain. Pt #3: Review of Pt #3’s ED medical record revealed Pt #3 arrived in the ED on 07/17/2023 at 10:22 AM with a chief complaint of right side pain. Per review of Pt #3’s ED record, VSs were taken at 10:24 AM and not again prior to discharge at 1:55 PM (3 hours and 31 minutes later) as per policy. Review of Pt #3’s ED Medical record revealed there was no documentation of a focused nursing assessment (i.e. Gastrointestinal & Genitourinary) addressing Pt #3’s complaint of right sided pain. Per Pt #3’s ED medical record there was no documentation of a pain assessment; Pt #3 received an IV injection of Dilaudid (Pain medication) on 07/17/2023 at 11:45 AM, and there was no documentation of a pain re-assessment. Pt #4: Review of Pt #4’s ED medical record revealed Pt #4 arrived in the ED on 09/09/2023 at 5:41 PM with a chief complaint of abdominal pain and vomiting. Review of Pt #4’s ED record revealed there was no documentation of a BP until 6:31 PM; 50 minutes after arrival to the ED. Pt #4 was discharged at 8:19 PM (2 hours and 38 minutes) and no vital signs were taken prior to discharge. Review of Pt #4’s ED medical record revealed there was no documentation of a focused nursing assessment (i.e. Gastrointestinal & Genitourinary) addressing Pt #4’s complaint of abdominal pain. Pt #4 received Toradol for pain on 09/09/2023 at 6:17 PM, and there was no documentation of a pain re-assessment. Pt #4 received Zofran for vomiting at 6:26 PM and there was no documentation of a nursing evaluation of Pt #4’s response to treatment. Pt #5: Review of Pt #5’s ED medical record revealed Pt #5 arrived in the ED on 07/10/2023 at 2:16 PM with a chief complaint of chest pain; Pt #5 was discharged at 5:16 PM. Pt #5’s VSs were last checked at 2:20 PM (2 hours and 56 minutes) and were not re-checked prior to discharge. Per medical record review, there was no documentation of staff checking Pt #5’s temperature. Review of Pt #5’s ED medical record revealed there was no documentation of a focused nursing assessment (i.e. Cardiac & Respiratory) addressing Pt #5’s complaint of chest pain, and there was no documentation of a pain assessment. Pt #6: Review of Pt #6’s ED medical record revealed Pt #6 arrived in the ED on 11/17/2023 at 12:35 PM with a chief complaint of vaginal bleeding and cramping. Per review, there was no documentation of a focused nursing (i.e. Genitourinary) assessment addressing Pt #6’s complaints. Pt #7: Review of Pt #7’s ED medical record revealed Pt #7 arrived in the ED on 08/25/2023 at 2:06 PM with a chief complaint of vomiting and sweating; Pt #7 was discharged home at 7:54 PM (5 hours and 48 minutes). Per medical record review, there was no documentation of nursing assessments and evaluations (i.e. Gastrointestinal & Genitourinary) addressing Pt #7’s complaints of nausea and vomiting throughout Pt #7’s ED visit; and there was no documentation of a pain assessment. Review of Pt #7’s VSs revealed Sp02 was 88% (normal >92%) and RR was 22 (normal <20) at 2:09 PM; there was no documentation of VSs being rechecked until 7:08 PM; 5 hours later. Pt #8: Review of Pt #8’s ED medical record revealed Pt #8 arrived in the ED on 11/14/2023 at 1:01 PM with a chief complaint of urinary frequency, flank pain, and pregnancy; Pt #8 was discharged at 4:57 PM. Pt #8’s VSs were last checked at 1:05 PM (3 hours and 48 minutes) and were not re-checked prior to discharge as per policy. Per Pt #8’s ED medical record review, there was no documentation of a focused nursing assessment (i.e. Gastrointestinal & Genitourinary) addressing Pt #8’s complaints of flank pain, urinary frequency, and pregnancy. Pt #9: Review of Pt #9’s ED medical record revealed Pt #9 arrived in the ED on 10/27/2023 at 11:45 AM with a chief complaint of cough, congestion, and shortness of breath. Per review, there was no documentation of a focused nursing assessment (i.e. Cardiac & Respiratory) addressing Pt #9’s complaints of cough and shortness of breath. Pt #10: Review of Pt #10’s ED medical record revealed Pt #10 arrived in the ED on 07/31/2023 at 2:30 PM with a chief complaint of asthma and shortness of breath; Pt #10 was discharged home at 4:44 PM. Review of Pt #10’s VSs checked at 2:33 PM revealed a RR of 24 (normal <20) and a BP of 175/101 (normal 120/80). Pt #10 last VSs were checked at 2:33 PM (2 hours and 1 minute) and VSs were not re-checked prior to discharge. Review of Pt #10’s ED medical record revealed there was no documentation of a focused nursing assessment (i.e. Cardiac & Respiratory) addressing Pt #9’s complaints of shortness of breath. Pt #10 was administered an albuteral nebulizer treatment and a prednisone tablet (steroids to treat shortness of breath) on 07/31/2023 at 3:19 PM; there was no documentation of a nursing evaluation of Pt #10’s response to treatment. Per interview with ED Director D, while reviewing medical records on 12/04/2023 between 2:00 PM and 5:00 PM , Director D confirmed the above findings. Director D stated that ED nurses should be completing a focused assessment on all ED patients based on the chief complaint and conducting a pain assessment and re-assessment using an appropriate pain scale. Director D stated that a nursing assessment/evaluation of symptoms (pain, nausea/vomiting) should be completed within an hour of providing an intervention. Director D stated that staff should check a full set of VSs on admission and within a hour of discharge. Director D stated that if VSs are abnormal, VSs should be repeated at least every hour. Per interview with Vice President (VP) of Nursing Services E on 12/04/2023 at 4:00 PM, when asked for a policy guiding ED Nursing Assessments,VP E stated that the facility does not have a policy specific to ED nursing assessments, but nursing staff should be following the assessment guidelines set forth in “Elsevier Clinical Skills” copyright 2023.”