HospitalInspections.org

Based on review of 1 out of 24 medical records (patient #1), the hospital and nursing staff failed to reassess and address patient #1's pain during a visit to the hospital's Emergency Department.

Patient #1 is a 14 year old who presented to the Emergency Department (ED) at Mercy Medical Center with complaint of back and leg pain. During triage patient #1 reported a pain score of 7 out of 10. Patient #1 was diagnosed with back sprain and referred for follow-up evaluation and treatment on an outpatient basis. Review of the medical record revealed no further documentation regarding the patient's pain. No further information regarding the pain level, no medication or non-medication interventions were provided for the patient while in the Emergency Department. The patient was in the ED for approximately 2.5 hours and per the medical record had taken 800 mg of Ibuprofen around the clock without relief. The hospital failed to reassess or address patient #1's pain as evidenced by the failure to document any information regarding the patient's pain beyond the pain score obtained at triage.