HospitalInspections.org

Based of document review and interview, it was determined that for 2 of 4 (Pt #38, Pt #42) clinical records reviewed for pain management, the Hospital failed to ensure that pain medication was adminstered timely to address complaints of severe pain.

Findings include:


1. The Hospital's Policy titled, "Pain Assessment and Management" (dated October 2021), was reviewed and required, " ... All patients have the right to systematic, individualized pain assessment and management ... patients should be offered multimodal analgesia (pain relief) ..."

2. The clinical record of Pt #38 was reviewed. Pt #38 presented to the emergency department on 2/5/2024, with a diagnosis of sickle cell. The nursing flowsheets included a triage pain assessment conducted on 2/5/2024 at 7:50 AM, indicating the patient reported severe pain (rated 8 out a scale of 0-10, 10=worst pain). Pt #38 was roomed at 8:00 AM. A physician's order for Morphine 10 milligrams was placed on 2/5/2024 at 8:20 AM. The Medication Administration Record (MAR) indicated that the Morphine was not administered until 9:46 AM (1 hour and 26 minutes after ordered).

3. The clinical record of Pt. #42 was reviewed. Pt. #42 presented to the (ED) on 12/28/2023 with a complaint of sepsis. The nursing flowsheets included a pain assessment conducted on 12/28/2023, at 1:45 PM, indicating the patient reported severe pain (rated at 8 out of a scale of 0-10). A physician's order for 1000 milligrams of acetaminophen (pain medication) was placed on 12/28/2023, at 1:50 PM. The MAR indicated that pain medication (acetaminophen) was not administered until 4:53 PM, more than 3 hours later.

4. On 2/5/2024 at 2:30 PM, an interview was conducted with an ED RN (E #24). E #24 stated that pain is assessed initially in triage and then assessed every 2 hours. E #24 stated that after the patient's labs are drawn; an order has been placed, and the patient has been roomed, pain medication can and should be administered as needed.