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Based on record review and interview, nursing staff in the emergency department failed to document pain reassessments after giving pain medication in 6 of 13 medical records reviewed (Patient #2, 7, 11, 12, 13 and 14) who required pain medication in a total of 20 records.

Findings include:

Review of facility policy titled, "Pain Management Policy," #6603064, dated 6/28/2019, revealed, "4. Assessment: Ongoing a. Patients with pain will be assessed at minimum once per shift (0700-1500, 1500-2300, and 2300-0700)...5. Pain and the effectiveness of pain management interventions are reassessed and documented using assessment tools appropriate to the patient. a. Pain is reassessed at a suitable interval following pain interventions. b. For pharmacologic interventions, the timing of reassessment should consider: drug, route, and dose."

A record review of Patient #2's closed emergency department record was conducted on 1/27/2020 at 2:03 PM accompanied by Director of Operations A who confirmed the following findings: Patient #2's medical record revealed that Patient #2 presented to the emergency department on 11/2/2019 at 7:53 PM with pain caused by sickle cell anemia. At 8:21 PM nursing staff documented Patient's #2's pain at a 9 on 0-10 scale (10 being the most severe) and Patient #2 received Dilaudid (narcotic pain medication) intravenously at 8:50 PM. Patient #2 received Toradol (non-steriodal anti-inflammatory medication) intravenously at 10:04 PM and Dilaudid again intravenously at 10:05 PM. There was no other documented pain assessment completed by nursing staff. Patient #2 was discharged home at 10:35 PM.

A record review of Patient #7's closed emergency department record was conducted on 1/27/2020 at 3:51 PM accompanied by Director of Operations A who confirmed the following findings: Patient #7's medical record revealed that Patient #7 presented to the emergency department on 12/26/2019 at 8:16 PM with pain caused by sickle cell anemia. At 9:00 PM nursing staff documented Patient #7's pain at a 10 on 0-10 scale (10 being the most severe) and Patient #7 received Dilaudid (narcotic pain medication) intramuscular on 12/27/2019 at 12:27 AM. Nursing staff documented Patient #7's pain at a 10 at 12:27 AM. Patient #7 received Norco (narcotic pain medication) orally at 2:08 AM. There was no other documented pain assessment completed by nursing staff. Patient #7 was discharged home at 2:09 AM.

A record review of Patient #11's closed emergency department record was conducted on 2/4/2020 at 9:26 AM accompanied by Director of Operations A who confirmed the following findings: Patient #11's medical record revealed that Patient #11 presented to the emergency department on 10/4/2019 at 2:23 AM with pain caused by sickle cell anemia. At 3:07 AM nursing staff documented Patient #11's pain at a 10 on 0-10 scale (10 being the most severe) and Patient #11 received Dilaudid (narcotic pain medication) intravenously at 3:07 AM. Patient #11 received Dilaudid again at 3:58 AM, 4:05 AM, and 4:09 AM. There were no other documented pain assessments completed by nursing staff. Patient #11 was discharged home at 6:24 AM.

In an interview with Director A on 2/4/2020 at 9:51 AM regarding pain assessments for Patient #11, Director A stated, "I don't see it on the vital signs," and after checking the nursing flow sheet and the medication administration record stated that no follow up reassessments were completed. Regarding the facility's policy for pain management, Director A stated that pain assessments are supposed to be once per shift after pain medication but that the expectation is within 30 minutes of intravenous medication.

A record review of Patient #12's closed emergency department record was conducted on 2/4/2020 at 9:57 AM accompanied by Director of Operations A who confirmed the following findings: Patient #12's medical record revealed that Patient #12 presented to the emergency department on 10/7/2019 at 10:07 PM with pain caused by sickle cell anemia. Patient #12 received Dilaudid and Toradol (an anti-inflammatory) at 11:48 PM. There were no documented pain assessments after Patient #12 received the pain medication. Per interview with Director A on 2/4/2020 at 10:08 AM regarding pain reassessments, Director A stated, "I do not see any pain reassessments in the flow sheets."

A record review of Patient #13's closed emergency department record was conducted on 2/4/2020 at 10:19 AM accompanied by Director of Operations A who confirmed the following findings: Patient #13's medical record revealed that Patient #13 presented to the emergency department on 10/15/2019 at 8:43 PM with pain caused by sickle cell anemia. Nursing documentation on the emergency department event time line revealed that Patient #13 rated pain at an 8 at 9:03 PM and a 6 at 11:54 PM. Pain reassessments are documented at 12:45 AM on 10/16/2019 and 12:47 AM on 10/16/2019. Tylenol was given orally at 11:54 PM and Dilaudid 0.5 mg (milligrams) was given intravenously at 11:55 PM on 10/15/2019. Dilaudid 1.0 mg was given intravenously at 12:45 AM on 10/16/2019, and Dilaudid 2.0 mg was given intravenously on 10/16/2019 at 1:33 AM, 2:44 AM, 4:23 AM, and 5:01 AM. There were no pain assessments documented by nursing staff after 12:47 AM on 10/16/2019.

A record review of Patient #14's closed emergency department record was conducted on 2/4/2020 at 10:43 AM accompanied by Director of Operations A who confirmed the following findings: Patient #14's medical record revealed that Patient #14 presented to the emergency department on 11/2/2019 at 9:21 PM with chest pain, anxiety, and a Crohn's flair up. Patient #14 received Toradol at 10:18 PM and left against medical advice at 11:42 PM. There were no pain reassessments documented after Patient #14 received pain medication. Per interview on 2/4/2020 at 10:47 AM, Director A stated, "The only thing I see is the sedation scale." Director A stated that the sedation scale is not for pain assessment/reassessment.

Interview on 1/27/2020 at 2:00 PM, Director of Operations A stated, "We expect staff to be completing an assessment of pain prior to discharge from the emergency department."


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