Menorah Medical Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, interview, policy review, and document reviews, the hospital failed to ensure nursing staff reassessed eight of 24 patients (Patient (P)10, P11, P13, P14, P15, P17, P18 and P23) sampled for a reassessment after administering narcotic medications. The failure to reassess has the potential to place all patients in the facility receiving pain medication at risk for undetected adverse reactions or uncontrolled pain.

Findings Include:

A review of the facility policy titled, Provision of Care Evidence Based Clinical Documentation, dated October 2020, showed, d) Pain Assessment, i) Comfort levels are assessed using appropriate pain scale for developmental age. ii) Pain is assessed with all assessments, reassessments, and vital signs. iii) Pain is assessed before, during, and after procedures/treatments.

Review of a document titled, PAIN Policy Updates- [DATE]th, 2020 showed, ...Reassessment should occur 15-30 minutes following administration of IV pain medication and 60 minutes following administration of P.O. [by mouth] or I.M. [intramuscular] pain medication ...

Patient 10

Review of P10's electronic record showed P10 was given oxycodone hydrochloride (HCL) 10 milligrams (mg) by mouth (PO) for pain on 03/12/21 at 1:49 PM. Review of the Medication Discharge Summary showed there was no reassessment documented following the administration of the pain medication.

Patient 11

Review of P11's electronic record showed P11 was given hydrocodone 5 mg with acetaminophen 325 mg (hydrocodone/APAP 5/325) mg PO for pain on 03/25/21 at 2:56 PM. Review of the Medication Discharge Summary showed there was no reassessment documented following the administration of the pain medication.

Patient 13

Review of P13's electronic record showed P13 was given oxycodone HCL 10 mg PO for pain on 03/08/21 at 1:20 PM. Review of the Medication Discharge Summary showed there was no reassessment documented following the administration of the pain medication.

Patient 14

Review of P14's electronic record showed P14 was given hydrocodone/APAP 5/325 mg PO for pain on 03/29/21 at 3:54 PM. Review of the Medication Discharge Summary showed there was no reassessment documented following the administration of the pain medication.

Patient 15

Review of P15's electronic record showed P15 was given hydrocodone/APAP 5/325 mg PO for pain on 03/18/21 at 8:22 AM. Review of the Medication Discharge Summary showed there was no reassessment documented following the administration of the pain medication.

Patient 17

Review of P17's electronic record showed P17 was given oxycodone HCL 10 mg PO for pain on 03/14/21 at 2:34 PM. Review of the Medication Discharge Summary showed there was no reassessment documented following the administration of the pain medication.

Patient 18

Review of P18's electronic record showed P18 was given oxycodone HCL 10 mg PO for pain on 03/23/21 at 3:04 PM. Review of the Medication Discharge Summary showed there was no reassessment documented following the administration of the pain medication.

Patient 23

Review of P23's electronic record showed P23 was given fentanyl 25 micrograms (mcg) intravenously (IV) for pain on 03/01/21 at 11:35 AM. Review of the Medication Discharge Summary showed there was no reassessment documented following the administration of the pain medication.

During an interview on 11/23/21 at 3:11 PM, the Director of Acute Care stated, We are required to reassess patients in 30 minutes after giving intravenous (IV) pain medication and 1 hour after giving oral pain medication. The Director of Acute Care confirmed that the nursing staff did not meet this requirement in eight of 24 records reviewed.

Based on policy and document review, the hospital failed to follow their policies and did not provide a medical screening exam to one (Patient 1) of 20 sampled patients who came to the emergency department (ED) seeking treatment between February 6 and July 6, 2019.

Failure to provide every patient seeking treatment in the ED with a medical screening exam has the potential to place patients to risk for delays in care and unidentified emergencies which could lead to further complications or death.

Findings included:

Review of the hospital policy titled, EMTALA-Medical Screening Examination and Stabilization Policy dated 05/01/19 showed, 1). When an MSE is Required. A hospital must provide an appropriate MSE within the capability of the hospital's emergency department, including ancillary services routinely available to the dedicated emergency department (DED), to determine if an emergency medical condition (EMC) exists (i) to any individual, including pregnant woman having contractions, who requests such an examination. An MSE is required when: a). The individual comes to a DED of a hospital and a request is made by the individual or on the individual's behalf for examination or treatment for a medical condition, including where (i) the individual requests medication to resolve or provide stabilizing treatment for a medical condition.

Review of an incident report showed that on June 2, 2019 at approximately 5:25 PM, ED staff advised Security Officers K and J that patient # 1 was in the ED lobby. Security Officers K and J responded and advised Patient # 1 he needed to leave the hospital. The incident report indicated Patient # 1 advised the Security Officers that he needed medical attention and that due to past history with the patient, Security Officers K and J advised him he would need to leave the property. Further documentation showed that Patient # 1 started to leave then turned back demanding the officers let him in to get medical treatment. Security Officer K contacted local law enforcement. Patient # 1 continued to refuse to leave until local law enforcement arrived. When local law enforcement arrived, the report indicated Patient # 1 walked to his vehicle and left hospital property, and that Security Officers K and J were back in service at 1738 hours (5:38 PM).

Refer to tag A2406 for details.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews, record and document review, the hospital failed to provide a medical screening exam (MSE) for one (Patient 1) of 20 sampled patients who came to the emergency department (ED) seeking treatment from February 6, 2019 through July 6, 2019.

Failure of the ED staff to perform a medical screening exam for every patient presenting to the ED has the potential to allow an EMC to be unidentified and delay necessary stabilizing treatment which could place patients at risk and could potentially lead to further complications or death.

Findings included:

Review of the hospital Dispatch Log for June 2, 2019 showed that at 5:25 PM to 5:38 PM hospital security performed a pedestrian check in the emergency room lot.

During an interview on 07/30/19 at 9:00 AM, Security Officer Supervisor L, stated that the facility only keeps video for 30 days and stated that the video of the June 2, 2019 incident had been deleted prior to the investigation.

Review of an incident report showed that on June 2, 2019 at approximately 5:25 PM, ED staff advised Security Officers K and J that patient # 1 was in the ED lobby. Security Officers K and J responded and advised Patient # 1 he needed to leave the hospital. The incident report indicated Patient # 1 advised the Security Officers that he needed medical attention and that due to past history with the patient, Security Officers K and J advised him he would need to leave the property. Further documentation showed that Patient # 1 started to leave then turned back demanding the officers let him in to get medical treatment. Security Officer K contacted local law enforcement. Patient # 1 continued to refuse to leave until local law enforcement arrived. The report indicated Patient # 1 walked to his vehicle and left hospital property, and that Security Officers K and J were back in service at 1738 hours (5:38 PM).

During an interview at 9:00 AM on 7/30/19 hospital Security Officer K stated, It was late afternoon about 4:00 PM or 5:00 PM and Patient # 1 had come in to the ED to check in and was having issues doing the admitting process. Security Officer K stated that Patient # 1 didn't want to follow the registration process. The nursing staff called me. There were a couple of nurses and the clerk trying to get patient 1 to check in and he just didn't want to. Finally, one of the nurses said since he doesn't want to check in, he needs to leave. So, we started walking him to the car and then he decided he wanted to come back in. Then he was flat refusing to leave saying he needed to see the doctor and then we called the Police Department and we told Patient # 1 that he could be charged with trespassing if he didn't leave. He still refused to leave. As soon as the Police Officer arrived Patient # 1 got in his car and left. Security Officer K stated We are supposed to respond and do what the clinical staff tell us to do. I can't say that it wouldn't happen any different today if the clinical staff told us to remove a patient. We can't make the clinical staff see a patient. We can only do what they say.

During an interview on 07/31/19 at 2:45 PM, the Vice President of Quality and Risk confirmed that Patient # 1 (MDS) dated [DATE] seeking care but did not receive a medical screening examination as required before hospital security officers directed him to leave.

During an interview on 07/31/19 at 4:15 PM, the former Director of ED Services stated that a staff member told her that there had been an incident with Patient 1 on 06/02/19. The former Director stated that she left employment with the hospital on [DATE] and was unable to investigate the incident. The former Director further stated that Patient 1 was well known to the ED staff and has a history of a traumatic brain injury. The former Director stated that Patient 1 would often refuse to register or tell staff what his medical complaint was. The former Director of ED Services stated that ED staff could have placed Patient 1 in an ED room and registered him after hearing his complaint. The former Director stated that Patient # 1 is usually alert and aware enough to make his own decisions and his needs known.