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Based on medical record review, patient and staff interviews Emergency Department (ED) staff failed to manage a patient's pain and perform pain reassessments for a patient in the emergency room for 2 of 11 medical records reviewed. (Patient #2 and Patient #23)

Findings included:

Review of the hospital policy titled "Pain Management", reviewed last 01/03/2022 revealed "...Purpose: The purpose of this policy is to promote practices that optimize the relief of pain for all patients and to ensure all patients receive the best level of pain control that can be safely achieved...Policy Guidelines: B. Pain Assessments: ...Documentation of pain assessment and response to pain relief measures will be done by all appropriate disciplines...C. Using the appropriate pain rating scale, the patient/family and healthcare team will collaborate to determine an appropriate pain management goal... Clinicians will respond promptly to a patient's report of pain and will attempt to meet a realistic pain goal. When this is not possible, the healthcare team will explain why the goal cannot be reached, and what can be done to keep the patient most comfortable...D...Nursing Personnel should contact provider when current orders do not meet patient needs for controlling pain..."

Review of the hospital policy titled "ED Nursing Documentation", reviewed last 08/19/2020 revealed "...Policy Guidelines, Nursing Procedure, The intake Registered Nurse (RN) will complete and initial primary assessment and assignment of an appropriate ESI level...Intake assessment and documentation must include:...Pain score. Once bedded: The primary nurse will complete...Serial focused reassessments based on patient acuity or at a minimum of every 4 hours...ESI (emergency severity index 1-most urgent to 5-least urgent) ... ESI level 3...every 3 hours..."

1. Closed medical record review for Patient #2, a 67-year-old female patient admitted to the emergency room (ED) on 05/21/2022 at 1918 with a complaint of " ...fall, and leg pain ..." Review of the Patient Care Timeline, triage note at 1920 by ED Registered Nurse (RN) #1 revealed "...EMS (emergency medical services) reports pt. (patient) had a seizure at Walmart, returned home and was unable to bear weight on L (left) leg ... Pt. c/o (complaint) L hip, L foot, L knee and R (right) ankle pain. Pt. CAOx4 (conscious, alert and oriented to person, place, and time of recent events) on arrival..." Review of the Patient Care Timeline at 1922 completed by RN #1 revealed "...Pain Assessment: Numerical (0-10) Pain Scale, Pain Score: 8-Eight (severe)...and at 1924 was assigned and ESI of 3-Urgent..." Review of the ED Provider Note, dated 05/21/2022 at 1947 by Physician's Assistant-Certified (PA-C) #2 revealed "History...she is concerned with left hip pain, left knee pain, and left foot pain...She also endorses some mild neck pain...Physical exam: Musculoskeletal:...Comments: Pain to left dorsum (back) of foot with some mild bruising noted just proximal (nearer to the center of the body) to the third fourth and fifth toes. Decreased ROM (range of motion) to left knee due to pain...Medical Decision Making...Patient had an x-ray done of her left foot that showed nondisplaced impacted fractures (break) of her second through fifth metatarsal (toe) necks...Her left hip x-ray showed probable greater trochanteric (hips outer area) fracture ... A CT (cat scan) of her hip and femur (thigh bone) were done because she continued to complain of hip pain radiating down to her femur and this showed an acute nondisplaced fracture..." Review of the Patient Care Timeline, Nursing notes, and Medication Administration Record (MAR) did not reveal any further pain assessments, pain interventions, or pain medication for Patient #2 during the course of her ED stay on 05/21/2022 at 1922 through 05/22/2022 at 0131 (6 hours). Review of the Physician Orders in the ED revealed no orders for pain medication was written during her ED stay from 1918 until 5/22/2022 at 0131 (6 hours) when Patient #2 was admitted as an in-patient to the medical floor.

Request to interview ED RN #1 revealed he was unavailble for interview.

Telephone interview on 05/26/2022 at 1155 with ED Physician and also the Chief Medical Officer, MD #4 who cared for Patient #2 in the ED revealed "...the expectation was that ED patient's pain be properly managed..." Interview revealed that pain management in the ED was currently being monitored and discussed with providers. Interview revealed after medical record review of Patient #2's pain assessment of 8, that MD #4 did not know why Patient #2's pain was not managed. Interview revealed the hospital's pain management policy was not followed.

Interview on 05/26/2022 at 1215 with ED Nurse Manager, RN #8, revealed "...my expectations are after the initial pain assessment was completed, that hourly pain reassessments be completed by the nurse..." Interview revealed hourly rounding should occur for all ED patients and pain reassessments should be completed with rounding. Interview revealed "When a patient's pain needs to be addressed the nurse alerts the physician face to face to request pain medication..." Interview after review of the Patient Care Timeline for Patient #2 revealed the triage nurse, RN #1 should have alerted MD #4 that Patient #2 needed pain medication ordered and documented the request. Interview revealed the ED Nurse Manager's expectation for response to Patient #2's initial pain assessment of 8, without any further pain reassessments for 6 hours, was not met. Interview revealed hospital policy for pain management was not followed for Patient #2.

Telephone interview on 05/26/2022 at 1255 with PA-C #2 revealed "...it would be up to nursing to do the pain assessments. Unless the nurse tells me, I don't give pain meds...I physically rolled her over to check her back and told her to let us know if she had pain. The nurse never once asked me for pain meds...I do not offer pain meds unless I am asked..." Interview revealed she remembered Patient #2, and she was not notified for pain medication orders for Patient #2. Interview revealed the hospital policy for pain management was not followed for Patient #2.

Telephone interview on 05/26/2022 at 1300 with ED RN #3 who cared for Patient #2 on 05/21/2022 revealed " ...I remember her having pain while moving from the stretcher to the bed...I don't remember any further complaints of pain ... I do ED reassessments prior to completing pain medication administration, after pain medication administration and during triage ..." Interview revealed RN #3 normally reported patient pain needs face to face to the ED provider when indicated. Interview further revealed RN #3 did not recall if pain focused reassessments for Patient #2 were completed every 3 hours. Interview revealed hospital policy for pain management was not followed.

2. Closed medical record review of Patient #23 revealed a 49-year-old patient admitted to the emergency room on 04/18/2022 at 0630 with complaints of shortness of breath. Review of the Patient Care Timeline at 0634 by RN #5 revealed "...Pain Assessment: Numerical (0-10) Pain Scale, Pain Score: 8-Eight (severe), Pain Type: Acute Pain, Pain Description: Aching, Pain Location: Rib cage, Pain Orientation: Left...and at 0638 and ESI of 3-Urgent was assigned..." Review of the Patient Care Timeline at 0829 completed by RN #6 revealed Pain Score: 8-Eight (severe). Review of subsequent Pain Assessments completed by RN #6 revealed, " ...1038 Pain Score 8-Eight (severe)...1231 Pain Score: 7-Seven (severe)..." Review of the ED Provider Notes dated 04/18/2022 at 0715 by MD #7 revealed "...presents in the emergency room with shortness of breath and pain and swelling to the right lower extremity...Clinical Impression: 1. Community acquired pneumonia of right lung, ...2. Cellulitis (inflammation of the skin causing redness and swelling) of right lower extremity..." Review of the Patient Care Timeline, Nursing notes, and Medication Administration Record (MAR) did not reveal pain interventions or pain medication administered for Patient #23 during the course of his ED stay on 04/18/2022. Review of the Physician Orders in the ED did not reveal pain medication orders written for Patient #23 during his ED stay on 04/18/2022 from 0630 until 1325 (6 hours) when Patient #23 was discharged home.

Request to interview MD #7 revealed he was unavailable for interview.

Telephone interview on 05/26/2022 at 1155 with the Chief Medical Officer, MD #4 revealed "...the expectation was for an ED patient's pain to be properly managed..." Interview revealed that pain management in the ED was currently being monitored and discussed with providers. Interview after medical record review of Patient #23's pain assessments of 7-8 over 6 hours revealed,"...we expect to treat pain and in this instance with right lower extremity swelling at the end of the day I would give pain meds. (medication)..." Interview revealed that MD #4 did not know why Patient #2's pain was not managed. Interview revealed the hospital's pain management policy was not followed.

Interview on 05/26/2022 at 1200 with ED RN #6 who cared for Patient #23 revealed "...normally pain is assessed every 1-2 hours. I don't remember the patient. I am concerned their pain was documented without doing something. Interview revealed after review of the Patient Care Timeline for Patient #23 that RN #6 did not remember pain interventions being completed. Interview revealed hospital policy for pain management was not followed for Patient #23.

Interview on 05/26/2022 at 1215 with ED Nurse Manager, RN #8 revealed "...my expectations are after the initial pain assessment was completed, that hourly pain reassessments be completed by the nurse..." Interview revealed hourly rounding should occur for all ED patients and pain reassessments should be completed with rounding. Interview revealed "...When a patient's pain needs to be addressed the nurse alerts the physician face to face to request pain orders needed..." Interview after review of the Patient Care Timeline for Patient #23 revealed the nurse should have alerted the physician Patient #23 needed orders for pain and documented the request. Interview revealed the ED Nurse Manager, RN #8's expectation for response to Patient #23's repeated pain assessment of 7-8 was not met. Interview revealed hospital policy for pain management was not followed for Patient #23.

NC00187976