HospitalInspections.org

Based on document review and interview, the facility failed to ensure a Registered Nurse provided evaluation, pain management and followed facility policy related to pain assessments and management for 4 of 10 patients
(patient #1, 5, 7 and 9).

Findings include;

1. Facility policy titled "Pain Standards, Assessment and Management of" last reviewed/revised 10/07/2013 indicated: " ...Purpose: ...all patients will have their pain assessed and have interventions implemented to help manage the pain effectively. Policy: All patients will have their pain assessed at least every shift (while awake) and as needed or specific to department. An assessment will include subjective and objective data obtained from the patient and others as appropriate. Information obtained will be used to individualize the plan for effective pain management. Procedure: PAIN ASSESSMENT: ...2. Assessment will include location; description; intensity; scale used; radiation location; duration; pain behavior described; pain parameters as seen in EMR [electronic medical records] pain assessment format. Pain intensity will be assessed using a 0 to 10 numerical scale if the patient has cognitive and language ability to do so. Alternate scales are available for those individuals with difficulty communicating, developmentally delayed individuals, those with language barriers and for children (appropriate age). Scales are: Adult 0-10 Scale, Face: 0-5 Scale, Behavior: Adult/Child 0-3 Scale ...PAIN MANAGEMENT: ...The objective of pain management will be to meet the patient's goals for pain relief. ...Pharmacologic, non-pharmacologic, and palliative measures will be implemented to decrease or eliminate pain. The patient's response to intervention for pain will be assessed and documented ...."

2. Review of patient #1's medical record indicated the following:
(A) The patient was admitted inpatient on 12/14/17, at 2311 hours.
(B) The patient's pain level was assessed on 12/22/17, at 1921 hours. The assessment indicated pain was located in patient's back and a pain level of 7/10. The patient received Tylenol 650 milligrams by mouth on 12/22/17, at 1921 hours.
(C) A pain level re-assessment was documented on 12/22/17, at 2006 hours. The re-assessment indicated pain was located in the patient's back and a pain level of 7/10.
(D) The MR (medical record) lacked documentation of additional pain management implementation. The next pain level assessment was on 12/23/17, at 0000 hours.

3. Review of patient #5's medical record indicated the following:
(A) The patient was admitted inpatient on 12/7/17, at 2140 hours.
(B) The patient's pain level was assessed on 12/8/17, at 0207 hours, on the admission assessment and indicated presence of pain. The MR lacked documentation of a pain level score, location, intensity, or the administration of pain medication.
(C) The patient's pain level was assessed on 12/8/17, at 0820 hours, on a physical assessment and indicated presence of pain. The MR lacked documentation of a pain level score, location, intensity or the administration of pain medication.
(D) The patient's pain level was assessed on 12/8/17, at 2000 hours, on a physical assessment and indicated presence of pain. The MR lacked documentation of a pain level score, location, intensity or the administration of pain medication.
(E) The patient had an order for Acetaminophen 650 milligrams every 4 hours, by mouth as needed for mild pain/fever. The order started on 12/7/17, at 2145 hours and discontinued on 12/12/17, at 1711 hours.

4. Review of patient #7's medical record indicated the following:
(A) The patient was admitted to the ED (emergency department) on 12/15/17, at 2015 hours, admitted inpatient at 2331 hours and transferred to medical surgical unit on 12/16/17, at 0007 hours.
(B) The patient's pain level was assessed on 12/15/17, at 2016 hours and indicated a pain level of 10/10.
(C) The patient's pain level was assessed on 12/15/17, at 2109 hours and indicated a pain level of 9/10.
(D) The patient was administered Hydromorphone (a pain medication) 1 milligram intravenous on 12/15/17, at 2109 hours.
(E) The MR lacked documentation of pain level re-assessment after the administration of a pain medication. (F) The next pain level assessment was documented on 12/15/17, at 2346 hours.

5. Review of patient #9's medical record indicated the following:
(A) The patient was admitted inpatient on 1/26/18, at 1620 hours.
(B) The patient's pain level was assessed on 1/28/18, at 0730 hours, on a physical assessment and indicated presence of pain. The MR lacked documentation of a pain level score, location, intensity or the administration of pain medication.
(C) The patient had a pain medication order for Tylenol 650 milligrams every 4 hours, by mouth as needed.
(D) The next pain level assessment was on 1/28/18, at 1628 hours.

6. Staff A3 (Administrative Director of Emergency Services) verified the medical record for patient #1, at 2:36 p.m., on 1/30/18.

7. Staff A5 (Administrative Director of Medical Surgical/Telemetry) verified the medical record for patient #7 at 3:39 p.m., on 1/31/18. He/she indicated a patient's pain level should be re-assessed within an hour after pain medication is administered.

8. Staff A5 verified the medical record for patient #9 at 4:43 p.m., on 1-31-18 and also indicated that there should be a pain level score, intensity and description of where the pain is located.

9. Staff A5 verified the medical record information for patient #5 at 5:17 p.m., on 1/31/18.