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Based on a review of facility documentation and staff interviews, the facility failed to assess the acceptable pain level of patients presenting at the emergency department for treatment, as well as failed to reassess the pain level post-intervention and prior to discharge as required by hospital policy and according to standards of nursing care for 6 of 20 patients. [Patients #4, 10, 13 and 16-18].

Findings were:

A review of 20 emergency department patient records revealed 8 of 20 [Patients #4, 10, 11-13 and 16-18] patients were never assessed regarding a pain level they would find acceptable. This made it difficult to determine if a patient had achieved an acceptable level of comfort post-intervention and/or prior to discharge.

For example, Patient #11 presented to the hospital emergency department on 9/29/19 with a chief complaint of "abdominal pain." His initial pain level at 9:47 a.m. was rated at a "7" on a 0-10 scale. A field in the nursing documentation for "acceptable pain" was left blank. He was administered a pain medication, Fentanyl, two times. At 11:00 a.m., his pain was reassessed and he still rated it as a "10." His pain level was not again documented prior to his discharge at 12:14 p.m.

For 6 of 20 [Patients #4, 10, 13 and 16-18] emergency department patients, an acceptable level of pain was never assessed. They had an initially high level of pain, were administered pain medication, but their pain level was never reassessed.

As examples:
- Patient #4 was admitted to the hospital emergency department on 7/30/19 with chief complaint of "back pain." Her initial pain level as assessed and documented as an "8" on a 0-10 scale. No acceptable level of pain was documented for Patient #4 and, though she received pain medication, her level of pain was never reassessed.
- Patient #13 was seen in the hospital emergency department on 9/21/19 with chief complaint of "shoulder pain." Upon admission, he rated his pain at a "10" on a 0-10 scale. No acceptable level of pain was documented for the patient.
- Patient #16 presented to the hospital emergency department on 9/23/19 with chief complaint of "ankle pain." His initial pain level was assessed at 9:03 a.m. as an "8" on a 0-10 scale. He was administered morphine at 11:02 a.m. There was no acceptable pain level documented for Patient #16 and the record included no documented reassessment of his pain.

Emergency department medical records were reviewed with Staff #8, ED Nurse Manager, on the afternoon of 10/15/19 at approximately 2:00 p.m. in a small conference room. When a pattern of patients having not been re-evaluated after reporting high levels of pain, or after medication was administered to address pain, was identified she stated, "We've been looking at that. We think the information isn't being pulled in from the medication administration record (MAR) and that's where nurses are documenting their reassessments." However, as the record review continued, MARs were also reviewed. The information was not documented there either. Staff #8 added, "I think there's no real prompt to reassess pain. That may be the problem." When asked if the hospital policy that an acceptable pain level be initially assessed and pain levels reassessed post-intervention also applied to the ED, Staff #8 said, "Yes, that's the expectation." She agreed that acceptable pain levels were frequently not documented in the records and that patient pain levels were not reassessed as required.

Facility policy #BSWH.NUR.GEN.001.P, entitled "Pain Assessment and Management Guidelines," effective date 10/09/2018, included the following:
"DEFINITIONS ...
Pain - An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Pain is whatever the individual experiencing it says it is; existing whenever the individual says it exists.

Pain Management - Alleviation or reduction of Pain to a level of comfort that is both acceptable and safe for the patient ...

Pain Management Interventions - Pharmacologic and non-pharmacologic interventions which reduce or eliminate Pain ...

POLICY
BSWH is committed to effectively screen, assess and reassess a patient's Pain with defined criteria and managing that Pain with appropriate Pain Management Interventions. BSWH leadership is responsible for Pain Management and promoting collaboration for safe and effective practice across various disciplines including providers and nursing ...

A Pain assessment using a Pain assessment tool appropriate for patient age, condition, and ability to understand may be performed:
- Upon admission/transfer to the patient care unit
- At least once a shift
- Prior to the administration of medications ordered for Pain Management
- After each intervention at a time appropriate to the route of administration, to evaluate the effect and determine whether modification is needed
- Upon establishment of care in an outpatient setting and at each visit thereafter for Pain Management
- During emergency department visits ...

Pain Assessment
Conduct comprehensive Pain assessments that guide clinical decisions before Pain medication administration: ...
- Assess and document for Pain such as:
- Patient's description of Pain
- Intensity using a 1-10 scale whenever possible
- Location, including radiation
- Duration, including persistent continuous Pain and intermittent Pain
- Aggravating and Alleviating factors ...

BSWH Standard Pain Scale ...
Administer medication based on physician or advanced practice provider order and BSWH Standard Pain Scale definitions below: ...
- Moderate Pain - corresponds to a score of 4-6 on a 10 point scale
- Severe Pain - corresponds to a score of 7-10 on a 10 point scale ...

Medication Range Orders ...
After administration of any non-pharmacologic and/or pharmacologic Pain management strategy, assess and monitor the effectiveness based upon the onset of action, peak effectiveness, and Sedation Level of the drug administered.
1. Within a timely manner based on medication peak effectiveness ...

Reassessment
Reassess and respond to patient's Pain through the following:
- Evaluation and documentation of response to Pain intervention(s) ..."