HospitalInspections.org

Based on document review and interview, the facility failed to follow their policy related to pain level assessment/reassessment of patients after interventions and/or prior to discharge for 1 of 20 medical records reviewed. (Patients #1).

Findings include:

1. Facility policy titled "STANDARDS OF PRACTICE, EMERGENCY DEPARTMENT" last revised on 3/2025 indicated the following: N. Standards of Care/Expectations: 3. Pain Assessment: a.) Initial Pain assessment and Pain re-assessments will be documented...upon arrival, after interventions and at discharge.

2. Review of patient #1's medical record indicated the following:
(a.) The patient arrived to the Emergency Department on 4/4/25 at 3:33 p.m. via walk-in for complaints of chest/back pain.

(b.) A pain level assessment was completed on 4/4/25 at 3:37 p.m., the patient had a pain level of 9 out of 10.

(c.) Patient #1's physician orders indicated an order for Percocet 5 milligrams-325 milligrams one tablet by mouth STAT was ordered on 4/4/25 at 5:17 p.m. and a nurse's note indicated the medication was administered to the patient on 4/4/25 at 5:21 p.m.

(d.) A pain level assessment was completed on 4/4/25 at 5:20 p.m., the patient had a pain level of 10 out of 10.

(e.) A nurse's note dated 4/4/25 at 6:52 p.m. indicated Patient #1 was administered 100 micrograms of Fentanyl intravenously.

(f.) The medical record lacked documentation of a pain level reassessment after interventions and/or prior to Patient #1's discharge to home on 4/4/25 at 8:14 p.m. as indicated in Clinical Summary.

3. During an interview with A1 (Quality Manager) on 10/1/25 at 1:00 p.m., A1 verified the medical record information for Patient #1.