HospitalInspections.org

Based on review of policy, medical record review, and interview, the facility failed to ensure pain management for 1 patient (#1) of 5 patients reviewed for pain control.

The findings include:

Review of the facility policy "Pain Assessment and Management" revised 5/2019, revealed "...8. Unexpected intense pain, particularly if sudden or associated with altered vital signs, such as hypertension, tachycardia, or fever, should be immediately evaluated and reported to the physician...3. The goals for pain management will include: b. Pain management based on the type of pain experienced (acute, chronic...neurologic...) 4. Ongoing Assessment of Pain/Interventions b. The presence (or absence) of pain will be reassessed and documented on all patients per routine unit vital signs or more frequently as needed...c. Pain intensity will be assessed at regular intervals based on clinical presentation...e. The nurse will document the date, time, and location of pain, pain scale, intervention, and pain scale after intervention during patient assessment..."

Medical record review of a Daily Focus Assessment Report (Nurse's report) dated 5/20/19 revealed Patient #1's documented pain level was 8 of 10 (scale where 0 no pain and 10 the worst possible pain) at 1:56 AM. Further review revealed the patient's pain level continued to be at a level 8 at 4:59 AM. Further review revealed no documentation the physician was notified of Patient #1's pain level. Continued documentation revealed no physician's order for pain medication.

Medical record review of Patient #1's electronic Medication Administration Record (MAR) revealed no documentation the patient received pain medication.

Interview with Registered Nurse (RN) #1 on 8/5/19 at 3:47 PM, in the conference room, confirmed Patient #1's pain level was documented at a level 8 at 1:56 AM and 4:59 AM on 5/20/19. Further interview confirmed the patient had no orders for pain medication. Continued interview confirmed there was no documentation Patient #1's physician was notified of the patient's pain.

Telephone interview with RN #2 on 8/7/19 at 12:45 PM confirmed the physician notification of the patient's pain level would have been documented in the medical record.

Telephone interview with Physician #1 on 8/7/19 at 6:30 PM revealed "...If he [Patient #1] would have told me [about pain] I would have ordered pain medicine...If the nurse had told me I would have ordered [pain medicine]..."

Telephone interview with Physician #2 on 8/8/19 at 9:50 AM confirmed he would have expected a medication order for Patient #1's complaint of headache and a pain level of 8.