HospitalInspections.org

Based on medical record review, staff interview, and review of facility policy, it was determined the facility failed to ensure that: 1) pain assessments are performed and documented during triage according to facility policy in four (4) out of 10 medical records reviewed [Patient (P) 1, 2, 5, and 9]; 2) interventions to alleviate or lessen pain are implemented according to facility policy in one (1) out of 10 medical records reviewed (P7).

Findings include:

1. Facility policy titled, "Emergency Department Triage," effective date: 12/27/2022, states, " ...Procedure: 1. Quick Triage: ... a. Components of quick triage include: ... ii. Vital Signs/Pain ..."

On 11/21/24 at 2:00 PM, P1, P2, P5, and P9's medical records (MR) were reviewed and revealed the following:

P1 arrived at the facility's Emergency Department (ED) on 10/28/24 at 18:41 (6:41 PM) with a chief complaint of abdominal pain. Vital Signs obtained during triage at 19:01 (7:01 PM) lacked evidence of a documented pain assessment.

P2 arrived at the facility's ED on 11/21/24 at 11:17 AM with a chief complaint of abdominal pain. P2's triage was started at 11:18 AM and his/her vital signs (temperature, blood pressure, pulse, respirations and oxygenation) were taken at 11:23 AM. P2 was evaluated by the provider at 12:12 PM. P2's medical record lacked evidence of a documented pain assessment during triage.

P5 arrived to the facility's ED on 10/28/24 at 5:56 PM with a chief complaint of assault. P5's vital signs (temperature, pulse, respirations and oxygenation) were taken at 6:26 PM. The medical record lacked documentation of a pain assessment during triage.

P9 arrived at the facility's ED on 10/21/24 at 5:27 PM with a chief complaint of back pain. P9's vital signs (temperature, pulse, respiration, blood pressure, and oxygenation) were taken at 5:29 PM. The MR lacked documentation of a pain assessment during triage.


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2. Facility policy, titled, "Pain Assessment/Management," effective date 1/10/23, states, "...1. Emergency Department (ED) Pain Assessment a. Personnel: The ED nurse will work in conjunction with the practitioners to evaluate a patient's level of pain and implement non-pharmacological as well as pharmacological treatments to alleviate or lessen the pain...c. Pain will be assessed initially and routinely. This pain assessment will be documented in the medical record. The nurse will escalate a report of new or different pain..."

On 11/21/24 a review of P7's medical record was conducted and revealed the following:

P7 arrived to the facility's ED on 6/10/24 at 4:15 PM with a chief complaint of back pain, headache, and motor vehicle crash. P7's triage was started at 4:29 PM. P7 had a pain assessment complete at 4:31 PM and he/she rated his/her pain as a "7- Severe pain."
At 7:08 PM, P7's ED nurse documented in the "ED Notes" that P7 "...no longer want[ed] to wait to be seen by a provider..." P7 left the hospital at 7:12 PM. The medical record lacked documentation that P7's pain was treated or re-assessed.

On 11/21/24 at 1:30 PM, an interview with Staff (S) 6, (Registered Nurse), was conducted. S6 explained that pain should be assessed during triage and if the patient is in a significant amount of pain, he/she would alert the physician and document the interaction in the medical record.

On 11/21/24 at 3:43 PM, an interview with S2, (ED Director), was conducted. S2 explained that pain should be assessed "at triage" and reassessed depending on the condition and severity. S2 also stated that the ED nurses "should be" documenting pain with vital signs.

These findings were reviewed with and confirmed with S2 and S3 (Risk Relations Manager) on 11/21/24 at 3:43 PM.