HospitalInspections.org

Based on document review and interview, the facility failed to ensure a Registered Nurse followed facility policy related to pain assessments for 1 of 10 Emergency Department patients (Patient #1).

Findings include:

1. Facility policy titled "Pain Management" with an approval date of 11/9/21 indicated the following: "...POLICY...1. Patients in all settings will be assessed/screened for presence, absence, and history of pain at point of service...8. Pain assessment (intensity and/or pain relief) will be assessed/screened and documented at a minimum: A. On admission/presentation to Emergency Department. B. Routine: based on assessment/reassessment policy, physician orders, and patients' status. C. After any known pain producing event. D. With each new report or behavioral indication of pain..."

2. Facility policy titled "Assessment and Reassessment" with an approval date of 3/10/21 indicated the following: "...POLICY...3. The results of assessment shall determine the frequency of reassessment...Related Documents...Attachment A: Scope of Assessment and Reassessment by Patient Care Unit...Medical Surgical...Elements Assessed...4. Pain...Time Frame...4. Minimally pain is assessed with vital signs...Elements assessed...VS (vital signs)...Elements Assessed...5. Minimally assessed every four (4) hours unless ordered otherwise or pt (patient) has comfort measures ordered...Emergency Department...Vital Signs...ESI (Emergency Severity Index/Acuity Level)-2: every 2 hours..."

3. Review of Patient #1's medical record indicated the following:

(A) The patient presented to the emergency department on 12/14/21 at 1558 hours via EMS (Emergency Medical Services) with a complaint COVID-19 positive and short of breath. Patient #1 had an acuity level of 2 on 12/14/21 at 1606 hours. Patient had a physician order to admit inpatient on 12/14/21 at 2052 hours and was boarded in the ED until 12/15/21 at 1352 hours until an inpatient room was available on the Medical Surgical Unit.

(B) The patient's pain level was assessed on 12/14/21 at 1604 hours and the patient's pain level was a 9. Patient #1's medical record lacked documentation of a pain level assessment on 12/14/21 at 1804 hours and 2004 hours.

4. During an interview with A4 (Clinical Supervisor Medical Surgical Unit) on 1/26/22 at 6:25 p.m., he/she verified the medical record information for Patient #1.