HospitalInspections.org

Based on policy review, medical record review, and interview, the hospital failed to ensure patients were screened and monitored for pain for 1 of 6 (Patient #1) sampled patients.

The findings included:

1. The hospital "PAIN MANAGEMENT GUIDELINES" policy revealed,"...A comprehensive pain assessment is conducted as appropriate to the patient's condition and the scope of care, treatment and services provided...Patients are screened for pain at the point of entry to the facility...Emergency Department [ED]...The patient's pain status is assessed...Each complete patient assessment per patient care area policy...Pain assessment includes: a. A pain intensity rating scale...b. Location...c. Quality...d. Onset...e. Duration...f. Aggravating/relieving factors...g. Relieving medications...Document pain assessment...in the medical record..."

2. Medical record review revealed Patient #1 presented to the ED on 5/26/19 at 9:34 AM with complaints of Back Pain, Nausea, Sore Throat, and was 26 weeks pregnant with twins.

Vital Signs recorded at 9:41 AM included a Pain Score of 8 with acute pain in the upper back.

The hospital was unable to provide a comprehensive pain assessment at the point of entry for Patient #1.

Vital Signs recorded at 11:52 AM included a Pain Score of 5. No other information about Patient #1's pain was provided.

Vital Signs recorded at 2:01 PM included a Pain Score of 4 in Patient #1's abdomen. No other information about the pain was included.

Vital Signs recorded at 3:11 PM included a Pain Score that was blank.

3. During an interview in the conference room on 6/10/19 at 9:16 AM, Registered Nurse (RN) #2 verified Pain Assessments are completed in the ED after pain medications are given and routinely every 2 hours. When asked about the Pain Score at 11:52 AM, RN #2 revealed, "I probably didn't click the button." RN #2 verified the Pain Score recorded at 3:11 PM was blank.