HospitalInspections.org

Based on document review, medical record review and interview, in one (1) of eight (8) medical records (MR) reviewed, staff did not follow facility policy and procedure to escalate a patient's pain to the physician.


Findings:

Facility Policy and Procedure titled "Pain Screening, Assessment, and Reassessment," last dated 5/5/23, states "uncontrolled pain is an urgent condition and warrants evaluation by a Licensed Independent Provider (LIP) ...RNs are responsible for immediate escalation to an LIP [for] ...pain level that continues to be unacceptable to the patient ..."

Review of the MR for Patient #1 revealed that the patient presented to the Emergency Department (ED) on 3/11/24 at 10:11 PM for a 1.0 CM scalp abscess with worsening pain. The ED Triage RN documented the patient's pain level as 10 out of 10.

Patient #1's pain was reassessed by an ED RN as a level 10 at 10:16 PM, 10:29 PM, and 10:33 PM. There was no documented evidence an MD was notified of the patient's level 10 pain prior to being evaluated by the physician at 11:13 PM.

Per interview with Staff K (Clinical Informatics RN), on 5/8/24 at 11:15 AM, during review of the medical record, Staff K confirmed these findings.