HospitalInspections.org

Based on interview, record review and a review of facility documentation, the hospital failed to ensure that pain medications were given in accordance with approved policies which required pain re-evaluations after medication administration for 1 of 10 sampled patients (#1).

Findings:

Patient #1's medical record reflected she was triaged in the Emergency Room (ER) on 12/27/15 at 1:39 AM. The nursing initial assessment note of 12/27/15 at 2:38 AM read, "Chief complaint detail: cough....Pain eval: pain level: 10. Description: sharp: Location: mid. Pain site: chest." The discharge order was entered at 4:45 AM. Physician orders of 4:45 AM on 12/27/15 read, "Ibuprofen 600 MG (milligrams) Tab PO (by mouth), once, routine." The patient was given Ibuprofen 600 MG one tablet by mouth at 5:02 AM. Pain was assessed at a "10" at the same time (on a scale of 1-10, with 10 being the worst). There were no further pain assessments or pain evaluations after this one.

A review of hospital's policy "Pain Management - Adult" read, "In the ED (Emergency Department), the patient's pain assessment and pain relief shall be evaluated in conjunction with the patient's individual clinical presentation. A pain management plan of care will be established based on the patient's clinical presentation and individual comfort." Thus, the administration of a medication, which brings pain relief, requires a subsequent evaluation of any pain relief.

There was no evidence that an evaluation of pain relief, as stated in this policy, was performed after the 5:02 AM administration. The policy was not followed.

A nurse's note of 12/27/15 at 5:15 AM read, "Discharge disposition: Home.... Discharge transportation: ambulatory." The patient was discharged home without another evaluation after pain medication was given.

During an interview of the Risk Manager at approximately 3:30 PM on 2/11/16, she confirmed the findings.