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Based on review of pain management policy approved by medical and emergency treatment record and interview it was observed that this requirement was not fully met.

Findings:

a. Reviewed Baptist Health System Safe Pain Management Policy (effective 2/19)

1) Page 3 Purpose of policy states:

"To promote the effective assessment of, safe treatment of and monitoring for side effects in
patients experiencing pain or undergoing painful procedures"

2) Page 9 of 13 , Paragraph D 2. Pain Assessment states :
" Pain is reassessed within 1 hour of any pharmacologic pain intervention."

3) Page 9 of 13, Paragraph D3 states:
"3. A pain score equivalent to 5 or above, will be considered intolerable. Notify the LIP if both pharmacologic and non-pharmacologic treatment modalities have been exhausted in attempting to reduce the pain to a level that is tolerable."


b. Review of emergency treatment record #1 40y/oM, emergency room visit on January 7, 2021 at 1:21pm it was observed that the patient whose chief complaint was neck pain originally described as 10/10 during EMS transport and during triage in ED 8/8 pain. The patient was administered Toradol 1ml intramuscarly and Valium 2mg-1tab at 1:38pm. There was no further documentation of pain assessment on a pain scale. The patient was re-evaluated by physician at 1:45pm and documented that patients condition was improving. The patient was discharged to home and left facility at 4:36pm. Discharge diagnosis "Acute Torticolis".

c. Interviewee #5. On January 25, 2021 at 12:45pm via telephone interviewed emergency physician who medically screened and treated patient on January 7, 2021. Physician explained history presented, care and treatment provided to patient and discharge diagnosis. She said on re-evaluation the patients condition did improve. She said she spoke to patients mother before patient was discharge. Did not explained if pain was re-assessed in detail. She said she felt he was stable enough to be discharged.

d. Interviewee #2. Interviewed Baptist Medical Center Safety Patient officer on January 15, 2021 in a conference room in the facility. Staff also reviewed medical record of 40y/o male January 7, 2021 ED visit and could only find one assessment of pain in chart 8/8 pain level at 1:34pm. There was no documentation of re-assessment of pain after 1 hour as per policy.

e. Reviewed medical treatment #2. record of 40y/o male re-visited emergency room at Baptist Medical Center on January 8, 2021 at 7:56pm due to pain in shoulder and neck. The patient was treated on January 7, 2021 for pain to neck. Discharge diagnosis Acute Torticolis, final disposition discharged home. On January 8, 2021 at 7:56pm the patient was triaged and then screened by a physician assistant medical provider. The patient was treated in emergency department with Flexeril 10 mg -1-tab oral once and Ultram 50mg 1tab oral once. Received order for discharge medication. On review of treatment record could not find a clear detailed re-assessment of the patients pain 1 hour after the pain medication was given. Patient was given medication for pain at 10:02pm on January 8, 2021. The patient was allowed to leave the emegency department right after pain medication was given.

f. Interviewee #3. On January 15, 2021 at 3:18pm in a conference room at Baptist Medical Center, interviewed provider who medically screen and treated patient. Explained chief complaint of pain of right shoulder and neck, history and treatment rendered to patient. He described the patient condition. There was no documentation of a clear re-assessment of pain. The patient's pain medication was ordered at 9:15pm on January 8, 2021. It was given by nursing staff at 10:02pm right before the patient was discharged from the emergency room.

g.Interviewee #4. On January 15, 2021 at 6:03pm via telephone interview nurse who assessed and administered medication to 40y/o male patient on the January 8, 2021 visit. The nurse explained the initial care and condition of paitent and triage. He described the situation in the emergency room being very busy at that time. It was explained the last time he saw patient was when he placed the patient in the secondary waiting room . In this room is where patients wait for lab results and imaging. He said when he last saw patient the patient was with the provider. He could not explain if the patient was re-assessed for pain.

h. On January 15, 2021 at 2:30pm in the conference room at Baptist Medical Center, interviewed Baptist Medical Center Safety Patient officer. Safety Patient Officer also reviewed medical record vist on January 8, 2021 of 40y/o male and could not find a a clear documetation of re-assessment of pain in treatment record. There was no documentation of re-assessment of pain after 1 hour as per policy.

i. Out of 15 Baptist Medical Center treatment records reviewed during this visit including the two mentioned above. A pattern was observed. 7 out of 15 records reviewed (47%) did not have documentation of a clear detail pain re-assessment documented in the emergency treatment record. There was only a generalized statement of patient being re-evaluated, dated and timed and remark that the patient's condition improved.

Based on review of pain management policy approved by medical and emergency treatment record and interview it was observed that the requirement for an appropriate medical screening examination was not fully met.

Findings:

a. Reviewed Baptist Health System Safe Pain Management Policy (effective 2/19)

1) Page 3 Purpose of policy states:

"To promote the effective assessment of, safe treatment of and monitoring for side effects in
patients experiencing pain or undergoing painful procedures"

2) Page 9 of 13 , Paragraph D 2. Pain Assessment states :
" Pain is reassessed within 1 hour of any pharmacologic pain intervention."

3) Page 9 of 13, Paragraph D3 states:
"3. A pain score equivalent to 5 or above, will be considered intolerable. Notify the LIP if both pharmacologic and non-pharmacologic treatment modalities have been exhausted in attempting to reduce the pain to a level that is tolerable."


b. Review of emergency treatment record #1 40y/oM, emergency room visit on January 7, 2021 at 1:21pm it was observed that the patient whose chief complaint was neck pain originally described as 10/10 during EMS transport and during triage in ED 8/8 pain. The patient was administered Toradol 1ml intramuscarly and Valium 2mg-1tab at 1:38pm. There was no further documentation of pain assessment on a pain scale. The patient was re-evaluated by physician at 1:45pm and documented that patients condition was improving. The patient was discharged to home and left facility at 4:36pm. Discharge diagnosis "Acute Torticolis".

c. Interviewee #5. On January 25, 2021 at 12:45pm via telephone interviewed emergency physician who medically screened and treated patient on January 7, 2021. Physician explained history presented, care and treatment provided to patient and discharge diagnosis. She said on re-evaluation the patients condition did improve. She said she spoke to patients mother before patient was discharge. Did not explained if pain was re-assessed in detail. She said she felt patient was stable enough to be discharged.

d. Interviewee #2. Interviewed Baptist Medical Center Safety Patient officer on January 15, 2021 in a conference room in the facility. Staff also reviewed medical record of 40y/o male and could only find one assessment of pain in chart 8/8 at 1:34pm on ED visit January 7, 2021. There was no documentation of re-assessment of pain after 1 hour as per policy.

e. Reviewed medical treatment #2. record of 40y/o male re-visited emergency room at Baptist Medical Center on January 8, 2021 at 7:56pm due to pain in shoulder and neck. The patient was treated on January 7, 2021 for pain to neck. Discharge diagnosis Acute Torticolis, final disposition discharged home. On January 8, 2021 at 7:56pm the patient was triaged and then screened by a physician assistant medical provider. The patient was treated in emergency department with Flexeril 10 mg -1-tab oral once and Ultram 50mg 1tab oral once. Received order for discharge medication. On review of treatment record could not find a clear detailed re-assessment of the patients pain 1 hour after the pain medication was given. Patient was given medication for pain at 10:02pm on January 8, 2021. The patient was allowed to leave the emergency department right after pain medication was given.

f. Interviewee #3. On January 15, 2021 at 3:18pm in a conference room at Baptist Medical Center, interviewed provider who medically screen and treated patient. Explained chief complaint of pain of right shoulder and neck, history and treatment rendered to patient. He described the patient condition. There was no documentation of a clear re-assessment of pain. The patient's pain medication was ordered at 9:15pm on January 8, 2021. It was given by nursing staff at 10:02pm right before the patient was discharged from the emergency room.

g.Interviewee #4. On January 15, 2021 at 6:03pm via telephone interview nurse who assessed and administered medication to 40y/o male patient on the January 8, 2021 visit. The nurse explained the initial care and condition of patient and triage. He described the situation in the emergency room being very busy at that time. He said the last time he saw patient was when he placed the patient in the secondary waiting room . This is the room where patients wait for lab results and imaging. He said when he last saw patient the patient was with the provider. Nurse interviewed could not explain if the patient was re-assessed for pain.

h. On January 15, 2021 at 2:30pm in the conference room at Baptist Medical Center, interviewed Baptist Medical Center Safety Patient officer. Safety Patient Officer also reviewed medical record vist on January 8, 2021 of 40y/o male and could not find a a clear documentation of re-assessment of pain in treatment record. There was no documentation of re-assessment of pain after 1 hour as per policy.

i. Out of 15 Baptist Medical Center treatment records reviewed during this visit including the two mentioned above. A pattern was observed. 7 out of 15 records reviewed (47%) did not have documentation of a clear detail pain re-assessment documented in the emergency treatment record. There was only a generalized statement of patient being re-evaluated, dated and timed and remark that the patient's condition improved.

j. On a follow-up interview with Baptist Health Systems Director of Accreditation and Regulatory compliance on April 14, 2022 at 3:47pm via telephone and email. It was explained that the Baptist Medical Center after their internal investigation of the case and after the onsite survey that was conducted on January 15, 2021. The facility did find opportunities for improvement and revised their Safe Pain Management policy, Emergency Nurse triage policy and provided pain assessment and re-assessment of pain refresher education for their emergency room staff.