HospitalInspections.org

Based on document review and interview, it was determined that for 2 out of 10 (Pt #5, Pt#8),emergency room patients the Hospital failed to ensure the policy governing pain management provided in the emergency department (ED) was followed. This has the potential to affect all patients who receive care by the emergency department with an average of 112 patients per day.

Findings include:

1. The policy titled "Pain Management (revised by the facility, 5/21)" was reviewed on 11/4/21 at approximately 12:15 PM. The policy noted "...Implementation...A. All patients...will be assessed for pain/comfort upon admission, twice in a 24 hour time frame and after interventions..."

2. Pt #5 Date of Service (DOS): 8/14/21
Diagnosis: Lightheaded. The record was reviewed on 11/4/21 at approximately 1:30 PM. The record noted Pt #5 was triaged in the ED at 1543 (3:43 PM) by the Registered Nurse (RN). The record lacked a pain assessment upon admission to the ED.

3. Pt #8 DOS: 9/11/21
Diagnosis: Shortness of Breath. The record was reviewed on 11/4/21 at approximately 2:00 PM. The record noted Pt #8 was triaged in the ED at 11:16 AM, by the Registered Nurse (RN). The record lacked a pain assessment upon admission to the ED. The record noted the Pt received Toradol 15 mg for pain on 11/4/21 at 1905 (7:05 PM). The record lacked pain assessment prior to and post Toradol. First pain assessment documented was on 9/12/21 at 10:16 AM (23 hours after admission to the ED).

4. During an interview on 11/4/21 at approximately 2:30 PM with the Clinical Practice Manager (E#2). E#2 verbally agreed the pain assessments wasn't done upon admission/ triage and before and after pain medication, and should have been.