HospitalInspections.org

Based on record review and interview, facility staff failed to document a complete initial pain assessment in 1 of 10 patients (Patient #8) and failed to document a reassessment of pain in 1 of 4 Emergency Department (ED) patients receiving pain medication (Patient #2) in a total of 10 Emergency Department medical records reviewed.

Findings Include:

A review of the facility's policy titled "Pain Management," last revised on 06/2020 revealed, "Assessment: An initial comprehensive pain assessment will be completed ... this will include location, intensity, and nature of the pain ... [Pain] reassessment will occur: After pain interventions, once sufficient time has elapsed for the treatment to be effective ..."

A review of the facility's policy titled "Standards of Care for Patients in the Emergency Department (ED)/Kidcare," last revised on 04/2022 revealed, "Pain Assessment: Assessed at: ...after interventions used to treat pain and have had adequate time to be effective ..."

A review of Patient #2's medical record revealed Patient #2 was a 15-year-old who presented to the ED on 01/17/2023 at 6:54 AM for a complaint of sudden onset of lower abdominal pain, nausea and vomiting. Patient #2's initial pain score on 01/17/2023 at 7:02 AM was documented as "abdominal pain; sharp; suprapubic (lower abdomen) area; 7/10." Patient #2 received IV Ketorolac (an anti-inflammatory) on 01/17/2023 at 7:31 AM and IV Tylenol on 01/17/2023 at 7:46 AM. There was no documented evidence of a pain reassessment on Patient #2 after s/he received pain medication. Patient #2 was discharged on 01/17/2023 at 11:37 AM. These findings were discussed with and confirmed per interview with Director of Nursing F on 01/17/2023 at 2:25 PM. When asked what the expectation is for a pain reassessment for IV Ketorolac, s/he stated, "Typically 15-30 minutes after medication is given, we would need a pain reassessment."

A review of Patient #8's medical record revealed Patient #8 was a 57-year-old who presented to the ED on 08/16/2022 at 9:53 PM for a complaint of shortness of breath and leg wounds. Further review of the medical record revealed Patient #8's initial pain assessment on 08/16/2022 at 10:07 PM was documented as, "Does the patient have pain: Yes." There was no documented evidence of the location, intensity, or nature of Patient #8's pain. There were no additional pain assessments documented for the remainder of the ED visit. Patient #8 was discharged on 01/17/2023 at 1:18 AM. These findings were discussed with and confirmed per interview with Director of Nursing F on 01/17/2023 at 1:50 PM. When asked about Patient #8's initial pain assessment, s/he stated, "[It] looks like that was kind of a miss on this one."