HospitalInspections.org

Based on policy review, medical record review and interview, nursing services failed to provide appropriate interventions and assessments related to pain for 1 of 3 (Patient #1) patient records reviewed.


The findings included:


Review of the hospital policy "Pain Assessment and Management" revised on 3/12/2019 and reviewed on 3/9/2021 revealed, "... Assessing for Pain: Nurses caring for patients with pain should perform initial and ongoing assessments of pain and communicate assessment data to colleagues...Patients are screened for pain during emergency department visits...approved pain tools for adults without cognitive impairment include functional pain assessment with the scale of None, Mild, Moderate and Severe...Reassessment of pain: pain will be re assessed according to changes in the patient's condition as well as the patient's perception of pain...Nurses are responsible for identifying the problem of inadequate pain management in patients and for intervening responsibly to achieve the best level of pain control possible...Documentation: Document pain history assessment on appropriate admission assessment tool. Document initial and ongoing assessments of pain in the patients record including the source of the patient's pain and severity using the appropriate tool based on the patient's age, condition, and ability to understand. Document any treatments or interventions administered and the patient's response to treatment..."


Medical record review revealed Patient (Pt.) #1 presented to Hospital #1 Emergency Department (ED) on 9/28/2021 at 5:09 PM with complaint of diarrhea for 2 weeks with loss of appetite, weakness, pain in flank area and frequent urination.


Review of the triage note for Pt. #1 dated 9/28/2021 at 5:41 PM, revealed Registered Nurse (RN) #1 documented Vital signs as: Heart rate 132 beats per minute (abnormal high, Respiration 20 breaths/minute, Blood Pressure 126/90, and Oxygen saturation 94 percent (%) on room air. Pain assessment: Alert, Sharp Severe pain to bilateral flank area. There was no documentation Pt #1 was administered any pain medication.


Review of the ED Adult Assessment for Pt. #1 dated 9/28/2021 at 7:40 PM and at 8:42 PM performed by RN #2 revealed there was no pain assessment documented.


Review of the Pain assessment for Pt. #1 dated 9/28/2021 at 9:01 PM, at the time of discharge, revealed RN #2 documented no pain symptoms.


In an interview on 2/25/2021 at 10:05 PM, the Director of Risk Management verified there was no documentation pain medication was administered for Pt. #1's complaint of severe pain on 9/28/2021 at 5:41 PM. and there was no documentation Pt. #1's pain was reassessed until Pt. #1 was discharged at 9:01 PM.


In a telephone interview on 2/25/2022 at 12:20 PM, RN #1 who triaged Pt. #1, stated she did not remember Pt. #1's visit on 9/28/2021. RN #1 stated after she triaged patient's they are handed off to the ED nurse. RN #1 stated she gives a verbal report to the ED nurse at the time of handoff and any reports of pain would be included in that handoff.


In an interview in the conference room on 2/25/2022 at 12:30 PM, RN #2 stated she did not remember named Pt. #1. After reviewing the medical record, RN #2 was asked if she was made aware of Pt. #1's pain being documented as severe by the triage nurse. RN #2 stated she did not remember Pt. #1 so she could not say if she had been informed of the pain by the triage nurse. RN #2 stated she had not reassessed Patient #1's pain upon receiving Pt. #1 from triage or during the ED visit except at the time of discharge.