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BAPTIST MEMORIAL HOSPITAL
RN SUPERVISION OF NURSING CARE
Tag No.: A0395
Based on policy review, medical record review, and interview, the hospital failed to ensure patients were screened and monitored for pain for 1 of 3 (Patient #1) sampled patients.
The findings included:
1. The hospital "PAIN MANAGEMENT GUIDELINES" policy revealed,"...A comprehensive pain assessment is conducted as appropriate to the patient's condition and the scope of care, treatment and services provided...Patients are screened for pain at the point of entry to the facility...Emergency Department [ED]...The patient's pain status is assessed...Each complete patient assessment per patient care area policy...Each complaint of pain ...When pain interventions are provided ...Pain assessment includes: a. A pain intensity rating scale...b. Location...c. Quality...d. Onset...e. Duration...f. Aggravating/relieving factors...g. Relieving medications...Document pain assessment...in the medical record..."
2. Medical record review revealed Patient #1 presented to the ED on 5/3/19 at 12:11 PM with complaints of headache, blurred vision, and tingling on her left side for 1 week. She was admitted to the hospital with a diagnosis of Transient Ischemic Attack (TIA).
Vital Signs recorded at 12:54 PM included a Pain Score of 6 with acute pain, which was constant and throbbing.
The hospital was unable to provide a comprehensive pain assessment at the point of entry for Patient #1.
The Pain Assessment Timer was restarted at 4:00 PM and 7:16 PM, but there was no pain assessment documented in the medical record.
Patient #1 was admitted to the 4th floor on 5/3/19 at 7:45 PM.
On 5/3/19 at 11:54 PM and on 5/4/19 at 1:21 PM, Patient #1 was administered Tylenol 650 mg (milligrams) for pain on the left side of her head. There was no documentation of the Tylenol's effectiveness.
On 5/4/19 at 6:11 PM, Patient #1 was administered Norco 5mg/325 mg for a pain score of 7. There was no documentation of the Norco's effectiveness.
On 5/5/19 at 1:40 PM, Patient #1 was administered Toradol 15 mg intravenously. There was no documentation of the Toradol's effectiveness.
The hospital was unable to provide documentation of complete pain assessments for Patient #1 on the following dates and times:
a. 5/4/19 at 12:54 AM, 2:50 AM, 1:21 PM, 3:47 PM, and 6:11 PM.
b. 5/5/19 at 8:00 AM, 1:40 PM, and 4:00 PM.
c. 5/6/19 at 8:30 AM.
3. During an interview in the conference room on 6/11/19 at 1:49 PM, the Director of Risk Management verified the pain assessments on Patient #1 were incomplete.