HospitalInspections.org

Based on review of policy, observation, medical record review and patient and staff interviews, the nursing staff failed to assess pain per hospital policy for 2 of 12 sampled medical records reviewed (Patient #2 and #9).

Findings include:

Review on 11/12/2019 of the hospital policy titled "Pain Management Policy" effective date 04/26/2017 revealed "...The management of pain requires assessment, reassessment and follow up utilizing objective measurement ...F. Reassessment: 1. Frequency: a) Every shift/change in caregiver ...b) Patients receiving PRN (as needed) medications ...ii. IV push short-acting PRNs (i.e. Ketorolac...): reassess patient immediately after administration or within one hour ..."

1. Observation of the emergency department (ED) on 11/13/2019 at 1540 revealed Patient (Pt) #9 was lying on a stretcher in the hallway of the ED.

Interview with Pt #9 revealed that she received two doses of pain medication while in the ED. Interview revealed the nurse assessed Pt #9's pain level prior to administering the medication. Interview revealed a nurse did not reassess Pt #9's pain level after the medication was administered.

Medical record review revealed Pt #9 was a 43 year-old female that presented to the ED on 11/13/2019 at 1126 complaining of abdominal pain. Review of Patient #9's "Patient Care Timeline" revealed documentation that on 11/13/2019 at 1134 Pt #9's reported pain level was 8 on a pain scale of 0-10. Medical record review revealed at 1227, Registered Nurse (RN) #4 administered 30 mg (milligrams) of ketorolac (pain medication) to Pt #9. Medical record review failed to reveal documentation of a pain score with administration of the pain medication. Medical record review failed to reveal documentation of reassessment of Pt #9's pain level within one hour of receiving the pain medication per hospital policy.

Interview on 11/14/2019 at 1000 with the ED Clinical Manager (CM) revealed the CM would expect to see documentation of a pain score when the medication was administered as well as documentation of re-assessment within one hour of an intervention.

2. Review of a closed medical record on 11/13/019 revealed Pt #2 was a 43 year-old male that presented to the ED on 08/05/2019 at 1655 complaining of fever and an abscess in the left axilla (armpit). Medical record review revealed documentation that at 2042 Pt #2's pain score was 8 on a 0-10 pain scale. Review revealed documentation that at 2045 Registered Nurse (RN) #2 administered 15 mg of ketorolac to Pt #2. Medical record review revealed documentation at 2141 (56 minutes later) Pt #2 reported a pain level of 7 on a pain scale of 0-10. Review failed to reveal evidence of a nursing intervention or notification to the provider of Pt #2's pain level. Medical record review revealed documentation that at 2257 a "Care Handoff" occurred and RN #1 gave report to RN #3. Further review revealed documentation that Pt #2 was discharged home on 08/06/2019 at 0041. Review failed to reveal documentation of Pt #2's pain assessment after the change in caregivers per hospital policy.

Telephone interview on 11/14/2019 at 0945 with RN #1 revealed that if a patient complained of a pain level of 7 out of 10, RN #1 would intervene and request an order for pain medication from the provider. Interview revealed if there was no documentation of an intervention for Pt #2's pain level,"it was not done."

Interview on 11/14/2019 at 0930 with RN #3 revealed she did not assess Pt #2's pain level during the "Care Handoff." Interview revealed RN #3 assessed Pt #'2s pain level at discharge (3 hours and 55 minutes after the administration of ketorolac). Interview revealed RN #3 documented a pain score of "0" in the medical record.

Interview on 11/14/2019 at 1000 with the ED Clinical Manager (CM) revealed the CM would expect to see an intervention documented for a patient with pain score of 7 out of 10. Interview revealed the CM would expect to see documentation of a re-assessment of patient's pain level within one hour of an intervention.

NC00155696, NC00155472