HospitalInspections.org

Based on medical record review, document review, and interview, it was determined that the facility, (a) did not ensure re-assessment of a patient for pain, and (b) develop policy and procedures specific to pain assessment and pain management.

Findings:

Review of the patient's medical record revealed that on 02/12/18, at 07:40 PM, Patient #1 was brought to the facility's Emergency Department (ED) by an ambulance as recommended by the her primary care physician , for further evaluation, post ultrasound.
At 07:51 PM, Patient #1 complained of abdominal pain with the intensity of 8 on pain scale of 1:10. At 08:24 PM, it was noted that patient refused MSO4 (Morphine sulfate) medication for pain.
At 09:50 PM, patient attending MD noted that "patient is re-checked and is resting well and comfortably." At 10:04 PM, patient's MD noted, "patient is rechecked and is resting well and comfortably." At 10:27 PM, patient's MD noted, "patient is rechecked and is resting well and comfortably." At 11:12 pm, prior to discharge, it was noted, "patient is rechecked and is resting well and comfortably."
There was no documented evidence that patient's pain was reassessed during her stay in the ED. There was no documentation of patient's pain level prior to discharge from the ED.


On 02/13/2018, at 11:20 AM, patient returned to the facility complaining of abdominal pain. At 11:37 AM, during triage, pain score was 7 on a pain scale of 1:10. Physician documented, "Gastrointestinal ...., tenderness: Mild, right upper quadrant, to palpation ...."
At 12:12 PM, patient's pain intensity was 8 on a pain scale of 1:10 which was controlled with MSO4 VIA IV push with variation in dosages.
At 05:46 PM, patient's pain was 0 out of 10 on a pain scale of 1:10.
Pain re-assessment was documented approximately 5 hours after administration of the MSO4.

On 05/24/2018, at 12 pm, during an interview with Staff C, Director of Quality Management, she stated that according to the facility's policy "Vital Signs and Reassessment," pain is viewed as a vital sign and shall be re-assessed every 4 hours unless otherwise indicated.

Review of the policy "Vital Signs and Reassessment," Reviewed 11/2016 states, "Vital signs will be reassessed and documented every 4 hours unless otherwise indicated."

The policy does not specifically address pain management and re-assessment.

Based on medical record review and interview it was determined that facility did not provide therapeutic diet for the patient as per physician's order.

Findings:

Review of the medical record revealed that on 02/13/2018, at 11:20 AM, Patient #1 returned to the Emergency Department, complaining of abdominal pain, and at 06:01 PM, patient was admitted under hospitalist care. At 12:41 PM, patient was placed on NPO status awaiting surgery, which was changed to clear liquid diet at 03:41 PM. There is no documented evidence in the medical record that would confirm that the patient received her clear liquid diet as prescribed.
The liquid diet order was discontinued at 08:30 PM, when the patient left the ED.

On 05/29/2018, at 02:23 pm, during an interview with Staff D, RN., Assistant Chief Nursing Officer in the ED she stated that Patient #1 was on Nothing by Mouth (NPO) status waiting for surgeon. She said, "She was hungry. She wanted to have surgery or come out of NPO."