HospitalInspections.org

Intakes: MS00027285

Based on staff interviews, family member interview, medical record reviews, review of facility policy and procedures the facility failed to ensure staff followed the facility's policy and procedure for "Pain Management" resulting in an incomplete assessment and treatment for a patient presenting to the Emergency Department experiencing right shoulder and knee pain after a fall for one (1) of three (3) medical records reviewed. Patient #1.

Findings Include:

During an interview on 01/07/2024 at 1:48 p.m., with the facility's Director of Quality (DOQ) it was revealed the facility received a complaint approximately one (1) month ago alleging the facility failed to assess and monitor a patient's pain while in the emergency department (ED). The DOQ stated the complaint was investigated and findings revealed the ED nurses did not assess the Patient #1's pain or report increased pain to the physician. In addition, failed to administer Acetaminophen (Tylenol) 650 milligrams as ordered, and fit and apply a shoulder sling to immobilize Patient #1's fractured shoulder.

During an interview on 01/08/2025 at 11:15 a.m., The Director of Nursing (DON) confirmed an order for Acetaminophen (Tylenol) 650 milligrams for Patient #1 was recorded by ED Physician #1 however, the medical record reveals no documented evidence Patient #1's pain was assessed or reassessed or that the medication (Acetaminophen) was administered.

During an interview on 01/08/2025 at 11:45 a.m., the facility's Pharmacist confirmed an order for Acetaminophen (Tylenol) 650 milligrams was written and somehow "pinned" by the physician while the patient went to the radiology department for a Computerized Tomography (CT) scan. The pharmacist further reported it does not appear the medication (Acetaminophen) was administered.

During an interview on 01/08/2025 at 12:51 p.m., Family Member #1 revealed his mother, Patient #1, has dementia and was clearly in pain when the staff picked her up from the stretcher and placed her in a wheelchair. The family member confirmed he did not ask the emergency room staff for pain medication for his mother, and the staff did not ask if she was in pain. He further confirmed he was sent home with a physician's name and phone number to set up an appointment with and was given written instructions for care and to give Tylenol for pain.

Review of Patient #1's medical record "Patient Care Timeline" (date 06/18/2024) revealed no documented evidence of a pain assessment or reassessment performed, no documented evidence of the administration of Acetaminophen (Tylenol) 650 milligrams ordered for pain, or documentation the patient was fitted with an arm sling for a "mildly impacted fracture of the humeral head neck," while in the E.D from 07:39 a.m. and 11:03 a.m.

Review of facility policy entitled "Pain Management" (effective date (12/20/2023) revealed "in acute care areas pain assessment shall be addressed with each scheduled patient body assessment, at least every shift, and as indicated by patients' complaint of pain. All other patient care areas shall utilize an established process to assess, reassess, document and report unrelieved pain as appropriate to their specific setting ...pain shall be reassessed within one (1) hour after administration of oral analgesic and within 30 minutes after IV analgesics ...The patients healthcare provider is notified of the patients' pain when treatment fails to reduce pain to a level acceptable to the patient."

The Exit conference was held on 01/08/2024 at 1:42 p.m. with the Director of Quality, Senior Director of Quality and Regulation, Senior Director of Emergency Services, and the Regulatory and Accreditation Coordinator. No additional documents were presented by the facility.