HospitalInspections.org

Based on policy review, closed medical record review and staff interview, the nursing staff failed to assess and reassess pain for 10 of 25 sampled medical records reviewed (#2, #4, #8, #24, #5, #7, #21, #19, #15 and #16).

The findings include:
Review of the hospital's policy, "Pain Management", revised 08/2015, revealed "...POLICY: A. All patients will have a comprehensive pain assessment completed on admission. B. The pain assessment should be based on the patient's self report of the level and intensity of the pain..." "PROCEDURE: Each patient will be assessed and monitored for the presence of pain 1. On admission... 12. Document pain assessment on the nursing flowsheet or electronic medical record ... H. ...Reassessment of pain in follow up after intervention will be within approximately one (1) hour ... "
Review of Hospital A's Assessment, Documentation and Nursing Process-Emergency Department Policy and Procedure, revised 11/2014 revealed ...REASSESSMENT a. Reassessment will be based on patient's vital signs and assessment, triage and the patient's condition as diagnostic tests and therapies are completed ...d. Those patients who have been triaged and placed in the waiting room will be re-assessed according to their assigned triage category as follows: ... 1. ESI Level 4 and 5-approximately every two hours 2. ESI Level 3-approximately every hour. ... 5. Nursing Interventions/Patient Response a. Will be documented in the medical record as they occur by qualified nursing personnel. B. Narrative notes will be required in the following circumstances: ...4. Change in the patient's condition ..."
1. Closed medical record review of Patient #2 revealed an 18 year-old female who presented to the labor and delivery unit on 03/05/2016 at 2215 for labor check and SROM (spontaneous rupture of membranes). Review of physician orders dated 03/06/2016 at 0625 revealed a telephone order for Percocet 10/325 one tablet by mouth times one as needed for pain. Review of medication administration record (MAR) dated 03/06/2016 revealed Percocet 10/325 one tablet administered by mouth on 03/06/2016 at 0937. Record review revealed no available documentation of reassessment by nursing of the patient's response to the Percocet therapy prior to discharge.
Interview with AS #2 (administrative staff) on 03/17/2016 at 1255 revealed nursing staff should reassess a patient's response to a pain intervention within one hour of the administration of pain medication and document the pain assessment on the nursing flowsheet, electronic medical record or in the nurse's narrative notes. Interview revealed "We should have reassessed pain after pain medication administered and before discharge. We should follow hospital pain policy." Interview confirmed there was no reassessment documented by nursing staff on the patient's response to Percocet administered on 03/06/2016 at 0937. Interview confirmed nursing staff did not follow hospital policy for reassessment after pain intervention.
2. Closed ED (emergency department) medical record review of Patient #4 revealed a 52 year-old female who presented to the ED on 01/10/2016 at 0735 for pain all over. Further record review revealed patient LWOT (left without treatment) on 01/10/2016 at 1140 (4 hours and 5 minutes after arrival). Record review revealed no available documentation of a pain assessment by nursing.
Interview with AS #1 (administrative staff) on 03/17/2016 at 1320 revealed nursing staff are expected to document a pain assessment on every patient and document the pain assessment on the nursing flowsheet, electronic medical record or in the nurse's narrative notes. Interview revealed "We should assess every patient's pain level on admission to the ED (Emergency Department). We should follow hospital pain policy." Interview confirmed there was no documentation of a pain assessment documented by nursing staff. Interview confirmed nursing staff did not follow hospital policy for assessment of pain on admission.
3. Closed ED medical record review of Patient #8 revealed a 30 year-old female who presented to the ED on 01/10/2016 at 1250 for chest congestion, cough and chest pain. Further record review revealed patient was discharged home on 01/10/2016 at 1731 (4 hours and 41 minutes after arrival). Record review revealed no available documentation of a pain assessment by nursing.
Interview with AS #1 on 03/17/2016 at 1330 revealed nursing staff are expected to document a pain assessment on every patient and document the pain assessment on the nursing flowsheet, electronic medical record or in the nurse's narrative notes. Interview revealed "We should assess every patient's pain level on admission to the ED (Emergency Department). We should follow hospital pain policy." Interview confirmed there was no documentation of a pain assessment documented by nursing staff. Interview confirmed nursing staff did not follow hospital policy for assessment of pain on admission.
4. Closed ED medical record review of Patient #24 revealed a 62 year-old male who presented to the ED on 11/27/2015 at 1258 for back pain, right sided neck pain and fall one week ago. Review of ED (emergency department) physician orders dated 11/27/2015 at 1611 revealed an electronic order for Morphine (medication for pain) 4 mg (milligrams) IVP (intravenous push) times one. Review of medication administration record (MAR) dated 11/27/2016 revealed Morphine 4 mg IVP administered on 11/27/16 at 1636. Record review revealed no available documentation of reassessment by nursing of the patient's response to the Morphine therapy.
Interview with AS #1 on 03/17/16 at 1300 revealed nursing staff should reassess a patient's response to a pain intervention within one hour of the administration of pain medication and document the pain assessment on the nursing flowsheet, electronic medical record or in the nurse's narrative notes. Interview revealed "We should have reassessed pain after pain medication administered. We should follow hospital pain policy." Interview confirmed there was no reassessment documented by nursing staff on the patient's response to Morphine administered on 11/27/2015 at 1636. Interview confirmed nursing staff did not follow hospital policy for reassessment after pain intervention.



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5. Closed ED medical record review of Patient #5 revealed a 50 year old male who presented to the ED on 01/10/2016 at 0737 for chest pain, nausea, vomiting and diarrhea starting 01/09/2016 at 2330. Further review revealed the patient left without treatment (LWOT) at 1122 (3 hours 44 minutes after arrival). Review of the ED triage record dated 01/10/2016 0737 through 1122 revealed no pain assessment or reassessment documentation by nursing staff was available for the this patient.
Interview with AS #1 on 03/17/16 at 1320 revealed nursing staff are expected to document a pain assessment on every patient and document the pain assessment on the nursing flowsheet, electronic medical record or in the nurse's narrative notes. Interview revealed "We should assess every patient's pain level on admission to the ED (Emergency Department). We should follow hospital pain policy." Interview confirmed there was no documentation of a pain assessment documented by nursing staff. Interview confirmed nursing staff did not follow hospital policy for assessment of pain on admission.



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6. Closed ED medical record review of Patient #7 revealed a 74 year-old female who presented to the ED via ambulance on 10/31/2015 at 1730 for fall in bathroom with pain with movement to the right knee. Review of triage notes revealed the patient had no pain during triage at 1736 and was scored as an ESI 4 (emergency severity index-triage level score). Review of physician orders dated 10/31/2015 at 1849 revealed an order for Morphine (narcotic pain medication) 4 milligrams intravenous push stat (immediately). Review of medication administration record (MAR) dated 10/31/2015 revealed Morphine was administered intravenously on 10/31/2015 at 1858. Review of physician orders dated 10/31/2015 at 2204 revealed an order for Dilaudid (narcotic pain medication) 1 milligram intravenous push stat (immediately). Review of medication administration record (MAR) dated 10/31/2015 revealed Dilaudid was administered intravenously on 10/31/2015 at 2346. Review of the record revealed no assessment of pain prior to administration of the pain medication and no reassessment of the response to the pain medication. Review revealed the patient was transferred via ambulance to another acute hospital with a diagnosis of complex fracture of the right femur. Record review revealed the patient departed the ED at 2350.
Interview with AS #1 on 03/17/2016 at 1255 revealed nursing staff should reassess a patient's response to a pain intervention within one hour of the administration of pain medication and document the pain assessment on the nursing flowsheet, electronic medical record or in the nurse's narrative notes. Interview revealed "We should have reassessed pain after pain medication administered and before transfer. We should follow hospital pain policy." Interview confirmed there was no assessment of pain after the initial triage at 1736 and no reassessment documented by nursing staff of the patient's response to pain medication administered on 10/31/2015. Interview confirmed nursing staff did not follow hospital policy for assessment of pain.
7. Closed ED medical record review of Patient #21 revealed a 43 year-old male who presented to the ED on 12/01/2015 at 1623 for pain to right hand due to an injury. Review of triage notes at 1626 recorded the patient described the hand pain as a 9 (scale of 1-10 with 10 the worst pain) and recorded an ESI level of 4. Further record review revealed patient LWOT (left without treatment) at 2031 (4 hours and 8 minutes after arrival). Record review revealed no available documentation of a pain reassessment by nursing.
Interview with AS #1 (administrative staff) on 03/17/2016 at 1320 revealed nursing staff are expected to document a pain assessment on every patient and document the pain assessment on the nursing flowsheet, electronic medical record or in the nurse's narrative notes. Interview revealed "We should assess every patient's pain level on admission to the ED (Emergency Department). We should follow hospital pain policy." Interview confirmed there was no documentation of a pain reassessment documented by nursing staff. Interview revealed Patient #21 had an ESI level of 4 and he should have been reassessed every two hours per policy. Interview confirmed nursing staff did not follow hospital policy for reassessment of pain.
8. Closed ED medical record review of Patient #19 revealed a 21 year-old female who presented to the ED on 03/14/2016 at 1342 for right lower quadrant abdominal pain. Review of triage notes recorded at 1416 revealed an ESI level of 3. Further record review revealed patient LWOT (left without treatment) at 1811 (4 hours and 29 minutes after arrival). Record review revealed no available documentation of a pain assessment by nursing.
Interview with AS #1 (administrative staff) on 03/17/2016 at 1320 revealed nursing staff are expected to document a pain assessment on every patient and document the pain assessment on the nursing flowsheet, electronic medical record or in the nurse's narrative notes. Interview revealed "We should assess every patient's pain level on admission to the ED (Emergency Department). We should follow hospital pain policy." Interview confirmed there was no documentation of a pain assessment documented by nursing staff. Interview confirmed nursing staff did not follow hospital policy for assessment of pain.
9. Closed ED medical record review of Patient #15 revealed a 24 year-old female who presented to the ED on 01/01/2016 at 1524 and was triaged at 1527 with a chief complaint of "here three days prior with abdominal pain. Diagnosed with ectopic (pregnancy). Given Methotrexate injection (medication to abort a non-viable pregnancy) and now has pain left side up to shoulders and into neck. Numbness in hands." Review revealed the patient was triaged as an ESI level 3. Further record review revealed patient was discharged home at 2047 (5 hours and 53 minutes after arrival). Record review revealed no available documentation of a pain assessment by nursing.
Interview with AS #1 (administrative staff) on 03/17/2016 at 1320 revealed nursing staff are expected to document a pain assessment on every patient and document the pain assessment on the nursing flowsheet, electronic medical record or in the nurse's narrative notes. Interview revealed "We should assess every patient's pain level on admission to the ED (Emergency Department). We should follow hospital pain policy." Interview confirmed there was no documentation of a pain assessment documented by nursing staff. Interview confirmed nursing staff did not follow hospital policy for assessment of pain.
10. Closed ED (emergency department) medical record review of Patient #16 revealed an 88 year-old female who presented to the ED on 01/01/2016 at 1136 for chest pain. Review of triage notes recorded at 1141 revealed the patient was triaged as an ESI 3. Review of nursing notes revealed the patient reported a pain level of 8 (scale 1-10 with 10 the worst pain) at 1203. Further record review revealed patient was discharged home at 1551 (3 hours and 48 minutes after reporting pain at a level of 8). Record review revealed no available documentation of a pain intervention or reassessment of pain by nursing.
Interview with AS #1 on 03/17/2016 at 1230 revealed nursing staff are expected to document a pain reassessment on patients triaged as an ESI 3 every hour per the ED policy. Interview revealed ED nursing staff failed to document a reassessment of the patient's level of pain after reporting a pain level of 8 at 1203 and prior to discharge at 1551. Interview revealed nursing staff failed to follow the ED policy for pain assessment.
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