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Based on interview, and record review, the facility failed to ensure the facility's policy and procedure (P&P) for pain management was implemented, for one of 30 sample patients (Patient 19), when:

For Patient 19, pain medication was not administered for one and a half hours when the pain score (numerical pain tool where mild pain is scored 1-3, moderate pain is scored 4-6, and severe pain is scored 7-10) was 8; and the pain score was not reassessed and documented following pain medication administration.

This failure had the potential to impact the health and treatment of the patients, and cause delays in patient care.

Findings:

A review of Patient 19's medical record was conducted on December 10, 2024, at 3:45 p.m., with the Infection Preventionist (IP). A facility document titled, "Triage," dated October 17, 2023, indicated Patient 19 presented to the Emergency Department (ED) for evaluation of "Chief complaint: pelvic pain...Severity: The severity of the pain was 8 (0-10 scale). The patient's goal for today is 2...Toradol [medication used to treat pain] - 30 mg [milligrams, unit of measure] IVP [Intravenous Push, medication to be administered in the vein] Placed at 10/17/2024 [October 17, 2024] 14:57 [2:57 p.m.], [Name of Provider]...Completed at 10/17/2024 [October 17, 2024] 16:07 [4:07 p.m.]...[Name of Registered Nurse]..."

An interview was conducted with the Quality Director (QD) on December 10, 2024, at 4 p.m. The QD stated the patient should have received medication for pain management sooner than one and half hours. The QD stated there was a delay in the pain medication being administered and there was no pain reassessment following the Toradol administration and this should have been done. The QD stated the pain reassessment should be completed after 15-30 minutes after IVP administration.

On December 11, 2024, at 9:10 a.m., a concurrent interview and record review of Patient 19's record was conducted with the Emergency Department Director (ED). The ED stated pain medication should have been administered timely to Patient 19 and this was not done. The ED stated the reassessment of pain should have been completed following the pain medication administration and this was not done.

A review of the facility P&P titled, "[Name of Facility] Pain Assessment and Management," dated February 2023, indicated, "...The patient experiencing pain will be appropriately assessed and interventions will be made in a timely manner to provide pain relief...Pain will be assessed, reassessed, and documented at regular intervals after the following...15-30 minutes after parenteral (intravenous) drug therapy and 1 [one] hour after oral administration..."

A review of the facility P&P titled, "[Name of Facility] Triage," dated June 2024, indicated, "...Triage assessment: Perform focused assessment of chief complaint to include the collection of subjective and objective data... Subjective data which may include, but not limited to, onset and progression of symptoms, location and description of problem, mechanism of injury, treatment prior to arrival and response and pain assessment... Reassessment every two (2) to four (4) hours and as needed..."