HospitalInspections.org

Based on document review of one (1) out of ten (10) patient medical records (Pt. #6) demonstrated the Emergency Department (ED) clinical staff failed to follow the clinical policy for pain management and provide pain management for patient #6 in a timely manner.

Findings:

The hospital's policy "Pain Management Policy," last updated July 12, 2023, states in part ...
"Emergency Department
A. Patients will be screened for pain. If the patient reports pain, an assessment is done consistent with the scope of care, treatment and services, and the patient's medical condition.
B. If a pain problem is ongoing and not associated with the presenting problem ...
C. Pain treatment may include pharmacologic and non-pharmacologic approaches.
D. Pain is reassessed after pharmacologic interventions once sufficient time has elapsed for the treatment to reach peak effect.
E. Pain management is included in the discharge evaluation as appropriate for the visit."

Review of Patient #6's medical record dated October 2-3, 2024, indicated the following:
* Patient #6 arrived at the Emergency Department (ED) at approximately 8:54 PM on October 2, 2024.
* The triage assessment completed on October 2, 2024, at approximately 9:17 PM indicated patient #6's pain level at that time was "8" on a 1-10 numeric pain scale. This information was entered into Patient #6's medical record on October 2, 2024, beginning at 9:00 PM.
* The Pain Management Policy defines Severe Pain as "Generally, a pain score that is within the benchmark range of 7-10/10, unless the patient identifies it as otherwise."
* On 10/02/2024 at11:04 PM, entry made indicating a reassessment of the patient was completed. This reassessment addressed the following: oxygen saturation, Glasgow Coma Score, skin color, level of consciousness (LOC), respiratory effort and pulse. No indication pain level was reassessed for changes although patient LOC was reported as alert.
* A medication order for Lorazepam (antianxiety medication) and Fentanyl (pain medication) was entered at 12:17 AM on October 3, 2024, and administered at approximately 12:59 AM, which is approximately 4 hours after the determination of "Severe Pain".
* Patient #6 was not seen by a Licensed Independent Practitioner until October 3, 2024, at 12:19 AM approximately 3 hours and 20 minutes after it was determined patient #6 was experiencing "severe pain". The physician note completed on October 3, 2024 at 3:48 AM, indicated the patient's pain at that time was "moderate" and reported; "[Patient #6] was given fentanyl and Ativan with improvement". Regarding the medications administered at 12:59 AM.

This information was verified by email on 01/22/2025 at 8:13 AM by the hospital's Patient Safety Program Manager.