HospitalInspections.org

Based on MR review, policy/procedure review, and staff interview, this facility failed ensure that patient's pain management was appropriately assessed and reassessed according to hospital policy in 4 of 10 ED patients (Pt. #1, 7, 8, and 9).

Findings include:

A review of the facility's policy titled, "Pain Management," dated April 2010, was completed on 11/9/2010 at 10:30 a.m. On page 2, in the section titled, "On Admission," #1 states, "Patients are assessed for pain using a 0-10 scale or appropriate alternative tool for objective measurement." In this type of scale 0 is the equivalent of no pain while 10 is the worst pain imaginable. In the section titled, "Ongoing Assessment/Treatment," #2 states, "After any pain management intervention, pain scores are reassessed within one hour."

During MR reviews, Dir A stated that it was the expectation in the ED that pain is assessed, "On admission, after intervention(s), and on discharge." Dir A agrees that the facility pain policy does not reflect the ED expectation or practice.

MR reviews for Pt.'s 2-10 were completed on 11/9/2010 between 11:05 a.m. and 1:16 p.m. accompanied by Dir A. All MRs were closed ED records.

A MR review was conducted on Pt. #1's closed ED record on 11/9/2010 at 9:30 a.m. Pt. #1 arrived at the ED on 6/5/2010 with complaints of back pain at 6:56 a.m. On admission Pt. #1 rated the pain at 9.5. At 9:45 a.m. Pt. #1 received a 60 milligram (mg) injection of Toradol (non-narcotic pain medication) and at 9:47 a.m. two tablets of Ultram (narcotic pain medication) for pain. Pt. #1 was discharged at 10:10 a.m. and reassessment of Pt. #1's pain was not completed.

These findings were discussed and confirmed by Dir A at 10:45 a.m.

Pt. #7 came to the ED on 6/3/2010 at 7:47 p.m. with complaints of right ear pain that had not improved with previous treatment. On admission to the ED Pt. #7's pain was rated as a 7. Pt. #7 received Dilaudid (narcotic pain medication) through an intravenous (IV) line at 8:35 p.m. At 8:31 p.m. there is a reassessment of pain as being rated a 5-this is documented as being 4 minutes prior to pain medication being given. There is no other documented pain reassessment for this dose of Dilaudid.

At 10:55 p.m. Pt. #7 received another dose of IV Dilaudid, however there is no corresponding pain rating or documented rating for pain reassessment within one hour as per facility policy.

Pt. #7 was kept in the ED for observation effective around 12:00 a.m. on 6/4/2010. At 12:40 a.m. Pt. #7 rated the pain at 5-6 and received another dose of IV Dilaudid. The next pain reassessment is documented at 2:20 a.m., more than 1 hour after the intervention, where pain is rated as 7 and Dilaudid was given again.

There is no further documentation of pain assessments or reassessments after 2:20 a.m. Pt. #7 was discharged from the facility at 8:50 a.m. on 6/4/2010.

Pt. #8 came to the ED on 10/16/2010 at 7:35 p.m. with complaints of left foot and ankle pain. On admission to the ED Pt. #8's pain was rated at 6-7. Pt. #8 was discharged from the ED at 8:55 p.m. and a reassessment for pain was not completed.

Pt. #9 came to the ED on 9/15/2010 at 3:01 p.m. with complaint of left flank (lower back) and left abdominal pain rated at 15 out of 10. Pt. #9 received Dilaudid (narcotic pain medication) through an intravenous line at 3:45 p.m. At 5:45 p.m. documentation indicates pain as being "better." This reassessment is not a score, and was done in excess of an hour of the intervention.

These findings were discussed and confirmed by Dir A at the time of the MR review.

Based on MR review and staff interview, this facility does not ensure that ED patient records are accurately timed by providers at the time of service for medical examinations (exams) in 6 out of 10 closed ED records reviewed (Pt.s #4, 5, 8, 9, and 10). By not documenting accurate times, a chronological record of events cannot be established.

Findings include:

In an interview with Dir A on 11/9/2010 at 10:15 a.m., A stated that providers are notified electronically on the "locator board" on a computer of patient's arrival to ED as soon as the HUC registers them. The provider is then expected to indicate (in the computer) which patient they will see and by doing so, this generates a time stamp for the time the provider sees the patient. The paper ED record is also to be timed when the provider sees the patient. These two times are supposed to coincide but according to Dir A they often do not.

MR reviews were completed on 11/9/2010 between 11:05 a.m. and 1:16 p.m. accompanied by Dir A. All MRs were closed ED records.

Pt. #4's MR was reviewed at 11:25 a.m. Pt. #4 arrived at the ED at 3:51 p.m. and was discharged at 6:08 p.m. on 6/6/2010. The provider documented the time of the medical exam on the ED Patient Record at 5:35 p.m. however the provider ordered x-rays at 3:55 p.m. indicating the medical exam of the patient was earlier than 5:35 p.m.

Pt. #5's MR was reviewed at 11:40 a.m. Pt. #5 arrived at the ED at 4:24 p.m. and was discharged at 9:46 p.m. on 6/6/2010. The provider did not indicate a time for the medical exam on the ED Patient Record.

Pt. #6's MR was reviewed at 12:40 p.m. Pt. #6 arrived at the ED at 7:24 p.m. and was discharged at 12:40 a.m. on 7/4/2010. There was a transfer of care with providers in the ED (change of shift), and the ED physician did not indicate the time care was assumed on the ED Patient Record.

Pt. #8's MR was reviewed at 12:55 p.m. Pt. #8 arrived at the ED at 7:28 p.m. and was discharged at 8:55 p.m. on 10/16/2010. The provider did not indicate a time for the medical exam on the ED Patient Record.

Pt. #9's MR was reviewed at 1:10 p.m. Pt. #9 arrived at the ED at 2:58 p.m. and was discharged at 6:00 p.m. on 9/15/2010. There was a transfer of care with providers in the ED for shift change, the accepting physician did not indicate a time on the ED Patient Record when care was assumed.

Pt. #10's MR was reviewed at 1:16 p.m. Pt. #10 arrived at the ED at 4:19 p.m. and was discharged at 10:05 p.m. on 11/6/2010. The provider did not indicate a time for the medical exam on the ED Patient Record.

These findings were discussed with and confirmed by Dir A at the time of the MR reviews.