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Based on medical record review, policy review and staff interview the facility failed to ensure patients' pain was properly assessed and managed according to facility policy. This affected three patients (Patient #5, #7 and #8) of 10 patients reviewed for nursing care.

Findings include:

1. The medical record for Patient #5 was reviewed on 08/14/24. Patient #5 was admitted to the emergency department (ED) on 06/19/24 at 8:00 AM with shortness of breath (SOB) and chest pain. The history and physical indicated this patient had hypertension, anemia and was receiving dialysis three times per week. Patient #5 stated the pain and SOB was similar to when she has fluid overload. Ativan 1 milligram (mg) was given by mouth at 8:22 AM for anxiety. A chest x-ray was completed which showed mild vascular congestion/edema with small bilateral pleural effusion.

Facility policy titled, "Emergency Department Assessment and Reassessment Intervals" (9/2021) was reviewed on 08/15/24. This policy instructed staff to complete vital signs (VS) which include BP (blood pressure), pulse, respirations, temperature and pain scale as part of their initial assessment. This policy further instructed staff to complete a pain scale within 5 to 90 minutes after IV (intravenous), oral, intramuscular, or subcutaneous administration of medications. All abnormal VS the physician or their designee should be notified.

The facility policy titled "Pain Management" (12/07/22) was reviewed on 08/15/24. This policy instructed staff to screen for the presence of pain during ED visits and at the time of admission. If pain was identified, perform a pain assessment which may include but is not limited to the following components as warranted by the patient's condition and clinical setting to include location, pain intensity rating, description along with aggravating factors and alleviating factors. This policy further instructed staff to reassess and document after each pain management intervention in a timely and comprehensive manner.

Review of Patient #5's medical record revealed no pain score was completed in the emergency department from 8:00 AM to 2:30 PM on 06/19/24. Patient # 5 went to dialysis at 2:30 PM where the first documentation of pain was at 2:55 PM listing chest pain as 9 out of 10 with the patient being medicated with Oxycodone and dialysis treatment starting at 2:57 PM. Nursing notes at 5:54 PM revealed this patient insisted on coming off dialysis early due to cramping in her legs with a 300 milliliter (ml) bolus of normal saline given and the physician was notified. Notes further revealed Patient #5 refused the dressing change to her central line with education provided but still refused. A pre-dialysis weight was documented at 54.4 kg and post-dialysis weight of 52 kg. Patient #5 was transferred back to the ED at 6:20 PM. Nursing notes upon return to the ED indicated this patient was crying stating "my legs are cramping, and I need something for it". The dialysis unit was contacted and informed to try Flexeril (muscle relaxer).

Nursing notes stated Patient # 5's mother called the ED at 6:23 PM stating "I've about had it with that place and am about to blow a gasket. My daughter was stuck in the ER all afternoon without a call light to let anyone know she needed help!". This RN informed the mother this patient just returned from dialysis, and they would do all they could to get her comfortable with the mother verbalizing understanding. Patient #5 was medicated with Flexeril at 6:27 PM. No documentation was found in the medical record of a pain rating before or after being medicated for the cramping. This patient was transferred to a medical-surgical unit at 10:07 PM.

Further review of the medical revealed vital signs were completed on 06/20/24 at 1:18 AM and 5:16 AM with no pain assessment documented. Flexeril 5 mg was given on 06/20/24 at 5:20 AM with no pain level documented. The first pain level documentated on the medical surgical unit was on 06/20/24 at 8:00 AM of of 0 out of 10. Patient #5 was discharged home on 06/20/24 at 12:54 P.M.

Review of Patient #5 medical record revealed the patient returned to the ED on 07/10/24 at 10:20 AM stating their port was malfunctioning during dialysis on Monday and it was supposed to be replaced next week but now it felt like something was stabbing them. Physician notes stated this patient was complaining of a stabbing pain on the right side of the chest and she did not feel it was her heart. Orders were written on 07/10/24 at 12:17 PM to consult interventional radiologist due to a poorly functioning peripheral catheter.

Patient #5's medical record review revealed the first pain assessment was documented on 07/10/24 at 11:10 AM as a 8 out of 10 with no description of where the pain was. Patient #5 was medicated with .5 mg Dilaudid as a one time order with a 5 out 10 pain level recorded at 12:38 PM. Patient # 5 was medicated with 650 mg Tylenol at 9:47 PM with a pain level of 5 out 10 recorded then 0 out 10 at 10:47 PM.

Review of Patient #5's vital signs completed on 07/10/24 at 11:33 PM, 07/11/24 at 5:09 AM and 7:50 AM revealed the residents pain was not assessed with vitals. The next documentation of a pain assessment was at 8:25 AM on 07/11/24 of 10 out of 10. Patient # 5 was discharged home on 07/11/24 at 6:11 PM.

The findings of not documenting a pain assessment upon admission, with vital signs, and with medication administration for Patient #5 as the facilities policies instruct was verified with the manager of the ED (Staff E) and Staff C through interview on 08/14/24 at 3:00 PM.

2. The medical record for Patient #7 was reviewed on 08/14/24. Patient # 7 was admitted to the emergency department (ED) on 08/08/24 at 5:14 PM after a fall at home. Nursing notes on admission listed a pain of 5 out of 10 on their right side and back at 5:17 PM. The physician ordered a CT scan of the abdomen, pelvis and chest with results showing fractured ribs. Plan was written to admit for observation due to multiple rib fractures and increased pain.

Review of Patient #7's medical record revealed Tylenol was given at 11:17 PM and the patient was transferred to the oncology floor on 08/09/24 at 12:28 AM. Vital signs were completed at 12:36 AM, 7:19 AM and 11:35 AM but no pain assessment was documented during these times. Patient #7 was discharged home on 08/09/24 at 1:30 PM with discharge instructions.

The findings of not following the facility policies in regards to completing a pain assessment for Patient #7 when vital signs were completed was verified with Staff C through interview on 08/14/24 at 5:10 PM.

3. The medical record for Patient #8 was reviewed on 08/14/24. Patient #8 was admitted to the emergency department (ED) on 08/11/24 at 1:41 PM with an inguinal hernia which was enlarged and painful.

Review of Patient #8's medical record revealed no pain assessment was completed on admission or the entire time in the ED. Patient # 8 went to the operating room at 4:57 PM for hernia repair.

Patient #8's medical record revealed the first pain assessment was documented at 8:11 PM of 0 out of 10 and hourly in recovery. This patient was transferred to the intermediate care unit on 08/11/24 at 9:15 PM with the first documentation of pain at 10:11 PM of 4 out of 10. Patient #8 was medicated with .5 mcg of Dilaudid at 10:15 PM. No re-assessment of pain was completed with the next pain assessment documented of 4 out of 10 on 08/12/24 at 2:12 AM and again medicated with .5 mcg of Dilaudid. The record did not include a description of where the pain was located.

The findings of no evidence Patient #8's pain assessment was completed upon admission or when pain medication was administered were verified with Staff C through interview on 08/14/24 at 5:10 PM.
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