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Based on record review and interview, the hospital failed to ensure emergency department patients were being properly assessed for pain and wounds were properly assessed and treated appropriately. This affected two (Patients #1 and #2) of twenty medical records reviewed. The census was 53.

Findings include:

1. Record review revealed Patient #1 arrived via ambulance on 03/22/22 at 3:16 PM complaining that he had fallen off of an electric scooter, hit his head and loss consciousness. At 3:18 PM the patient stated he had pain and rated it an eight on a scale of 1-10 (0 being no pain and 10 indicating the worst pain possible). The nurse did not document the location, intensity, alleviating factors, aggravating factors, current pain management, onset or any other descriptive information to ensure an appropriate pain assessment was completed. The triage nurse documented Patient #1 arrived at the emergency department with multiple abrasions to the right side of the face, shoulder and leg. His pain was not reassessed.

At 3:41 PM the CT scan was completed. At 4:23 PM the CT scan preliminary results were noted as "No evident acute intracranial abnormality. Mild right frontotemporal subcutaneous soft tissue swelling extending to the right cheek."

At 4:29 PM, Toradol 15 milligrams (mg) and Zofran 4 mg was ordered via intravenous route and given at 4:54 PM by Staff M. At 5:04 PM emergency staff documented Patient #1 the patient was discharged stable with family. The patient was provided with a diagnosis of contusions of other part of the head and multiple abrasions. There was no other documentation on the assessment of the abrasions or for treatment of the abrasions noted in the medical record. There was no further pain assessment documented in the medical record.

During interview on 04/27/22 at 12:55 PM with Staff I verified that staff did not assess or treat Patient #1's wounds or properly assess Patient #1 for pain and provide proper re-assessment on 03/22/22.

2. Medical record review revealed Patient #2 arrived in the emergency room via ambulance on 03/25/22 at 10:58 AM with a chief complaint of head laceration and all-terrain vehicle (ATV) accident causing injury. The patient was triaged at 11:01 AM and the nurse noted the patient had a laceration to the right side of the head with no complaints of loss of consciousness. On 03/25/22 at 11:02 AM vitals were obtained. No pain assessment was completed until 1:50 PM. The patient rated pain to the "lower, right, left" shoulder as a 10 at that time. On 03/25/22 at 1:28 PM the physician ordered acetaminophen 975 mg to be given by mouth once. On 03/25/22 at 1:48 PM the acetaminophen order was acknowledged by Staff M. There was no other pain assessment completed.

Review of the ED Provider note revealed the patient was riding her all terrain vehicle without a helmet when she flipped, landing on her right side. The patient complained of sharp pain in the head, right shoulder and back. The patient received six sutures to the head to close the abrasion. X-rays were completed and noted a small compression fracture in the 10-11 thoracic vertebrae. The patient was discharged and signed Against Medical Advice (AMA) paperwork on 03/25/22 at 4:20 PM.

During interview on 04/27/22 at 1:20 PM revealed with Staff I verified that pain should be assessed during triage if possible and throughout the stay. Staff I verified that there was no further pain assessment after the first assessment was noted on 03/25/22 at 1:50 PM.

Review of the hospital policy titled "Pain Management", dated May 2015, revealed all patients will be screened for pain on admission. A pain assessment to include location, pain intensity rating, description of pain, onset, duration, pattern, aggravating factors, alleviating factors, current pain management interventions and to establish a comfort goal with the patient will be conducted. Pain is to be reassessed and documented on after each pain management intervention is provided in a timely and comprehensive manner appropriate to the circumstances to ensure safety and efficacy. Staff should continue to reassess pain until the patient is satisfied with the pain relief and/or until pain is managed at or less than the comfort function goal. If pain is unrelieved discuss the need for adjustment to individualize care for each patient. The nurse should document the following pertinent information pertaining to pain: screening, assessments, interventions, reassessments following interventions and education.

Review of the hospital policy titled, "Wound Care Including Dressings, Negative Pressure Wound Therapy (NPWT), Removal of Drains, Packing, and Pressure Injury Care Including Prevention", dated 10/26/21, revealed dressing applications will be performed by the registered nurse or delegated to an LPN. Aseptic technique is to be followed when applying a dressing when indicated. Wounds are assessed and measured at admission, assessed daily, and measured weekly thereafter. Wounds are also assessed and measured when there is a change in skin or wound condition. Dressings and packing should be disposed of per the Infection Control policy. In addition to the documentation guidelines for wounds in Perry and Potter, documentation should include: wound size measurements on admission, weekly and with any change in skin/wound condition. Daily documentation of pressure ulcer risk utilizing the Braden Scale, pressure injury location, stage, drainage, and odor will be done by the nurse. Documentation of dressing changes should include: time, date and type of dressing, number of pieces utilized and assessment of skin condition and/or wound site including: size of wound, drainage amount and character, and duration of application if intermittent dressing. The registered nurse or delegated nursing personnel will follow manufacturers recommendations on the wound care packaging for instructions on how to apply the dressing. Refer to Perry and Potter for a variety of wound care dressings and their use. Remove any source of skin irritation, if possible. Implement appropriate items from the Safe Skin Guidelines, as needed. Hands will be cleansed with soap & water or sanitizer before and after procedures. Gloves will be worn at all times during procedures and will be changed if moving away from the procedure to do another task, then returning to the procedure. Items saturated with bodily fluid will be disposed of in a biohazard container. Documentation should include: location and description of wounds, incisions, drains, tubes, rashes, etc., including color, drainage, odor, and signs of infection. Measurements will be documented on admission (if present on admission) and weekly. Specific care for abrasions is as follows; If tissue is dry (with scab): Cleanse with soap & water, saline, or wound cleanser, pat dry, leave open to air. If tissue is moist (no scab): Cleanse with saline or wound cleanser, pat dry, cover with non-adherent layer, dry dressing, and change daily.