HospitalInspections.org

Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure that 1). pain assessment and reassessments are performed in accordance with facility policy for one of 10 patients (Patient (P) 6); and 2). interventions to alleviate pain are implemented according to facility policy in two of 10 medical records reviewed (P7 and P10).

Findings include:

The facility policy titled, "Pain Management" effective 10/2021, stated, "A. Purpose: [Facility name] requires that pain be assessed in all locations where care is provided. When pain is identified, appropriate interventions or referrals are utilized and follow up evaluations and documentation ensues to assess outcomes. ..D. Procedure. 1. Pain Assessment...the presence or absence of pain continues to be evaluated and documented no less often than once every eight hours and upon discharge for inpatients and more frequently as necessary...G. Documentation ...b. Pain reassessment is completed within a maximum of one hour following pain medication administration and is documented ... Appendix A Pain/Sedation Screening ...Pain Severity Scales= mild 1-3, moderate 4-7, and severe 8-10. "

1. A review of P6's medical records revealed that P6 presented to the ED on 12/7/24 at 1:24 PM, with a chief complaint of dental pain. At 1:31 PM, P6's pain was assessed at a 10/10. At 1:54 PM, P6 was medicated for pain with Toradol 30mg (milligrams) and at 2:00 PM with xylocaine 2% viscous solution (a medication used to numb the mouth). P6 was discharged at 2:05 PM. P6's pain level was not re-assessed after pain medication was administered or prior to be patient being discharged.

At 12:15 PM, an interview was conducted with Staff (S)4, the Emergency Department Nurse Manager. S4 stated that pain should have been re-assessed "ideally within 30 minutes of the patient being medicated, or at most one hour."

S4 confirmed that the emergency department follows the parameters documented in the "Pain Management" policy and procedure.

2) On 2/11/25, a review of P7's medical record was conducted with S14, the Nurse Professional Development Specialist. P7 presented to the Emergency Department (ED) on 1/11/25 at 1:56 PM, with a chief complaint of abscess (complicated). At 2:03 PM, P7's pain was assessed as a 9/10 on the numeric pain severity scale. At 3:40 PM, P7's CT Facial Bones with Contrast Impression stated, " ...Significant lucency surrounding left maxillary tooth (#13) could reflect dental caries with possible osteomyelitis ..." At 4:26 PM, P7's pain was assessed as a 6/10 on the numeric pain severity scale. P7 was discharged home at 4:27 PM with an oral antibiotic prescription of Clindamycin 300 mg (milligrams).

At 11:25 AM, upon interview, S10, the Emergency Department Chair Medical Director, stated, "typically a patient with tooth pain would receive a lidocaine block or some kind of pain relief medication." S10 further stated that P7 should have received medication for pain, and if the patient was offered pain medication and refused that would be documented. S10 confirmed P7's medical record lacked evidence that P7 received an intervention for pain.

On 2/11/25, a review of P10's medical record was conducted with S14. P10 arrived at the ED on 1/7/25 at 7:01 PM for an evaluation of vomiting and diffuse abdominal pain. At 7:10 PM, P10 reported pain as 8/10 on the numeric pain severity scale. At 9:10 PM, Zofran 4mg (milligrams) IV (intravenous) was administered for nausea. At 10:05 PM, the results of the CT scan of the abdomen and pelvis were unremarkable. At 11:35 PM, the patient was reassessed for pain and P10's pain was a 2/10 on the numeric pain severity scale. At 11:43 PM, P10 was discharged home.

At 12:00 PM, upon interview, S10 stated that if a patient presents with 8/10 pain, he/she would be given an immediate intervention for pain relief. S10 confirmed P10 did not receive any intervention for two hours.