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

Findings include;

1. Facility policy titled "STANDARDS FOR PAIN MANAGEMENT, ASSESSMENT, AND MONITORING" last reviewed/revised 3/2017 states under procedure on page 3: "...4. Assessment of pain or risk of pain should take place at the following times:
a) Upon admission.
b) With any new report of pain.
c) When completing routine assessments based on unit standards of care ...5. Document pain assessment, reassessment, pain/comfort management interventions, patient response to interventions, and patient education in the Electronic Medical Record (EMR) ...C. Guidelines for Pain Assessment and Patient Monitoring ...Type of Intervention ...PO [by mouth] Medications ...Re-assess pain level in about an hour ...IV [intravenous] Opioids ...Examples ...Hydromorphone ...Within approximately 15 minutes of the first dose, assess: ...Pain level ...."

2. Facility policy titled "STANDARDS OF CARE: MED-SURG [medical -surgical]" last reviewed/revised 10/2013 states under assessment on page 2: " ...Assess pain/comfort Q [every] 4 HRS [hours] ...Reassess pain level within 60 minutes after intervention...."

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

(A) The patient presented to the emergency department of Facility #1 on 9-18-17 at 1433 with a complaint of a neck injury.

(B) The patient's pain level was assessed on 9-18-17 at 1455 and 2144. The medical record indicated the patient's pain level was a 10 out of 10 for both assessments.

(C) The patient had a physician order for hydrocodone-acetaminophen (a pain medication) 5-325 mg (milligrams) tablet, one tablet every six hours PRN (as needed) for moderate pain score of 4-6 with a start date of 9-18-17 at 1520. The medical record indicated the patient received a dose on 9-18-17 at 1610 and lacked documentation of pain level assessment at 1610 and a reassessment at 1710 following the administration of the medication.

(D) The patient had a physician order for hydromorphone (Dilaudid) (a pain medication) 1 mg/ml (milliliters) intravenous with a start date of 9-18-17 at 2130. The medical record indicated the patient received a dose on 9-18-17 at 2136 and lacked documentation of pain level assessment at 2136.

E) The medical record lacked additional documentation of pain level assessments at 2010 on 9-18-17.

4. During an interview with staff member #12 (Quality and Accreditation Specialist) on 12-13-17 at 1:24 p.m., he/she verified the lack of documentation of pain level assessment and reassessment for patient #1 on 9-18-17.

Based on document review and interview, the facility failed to document an Emergency Department patients triage status in 1 of 10 Medical Records reviewed.

Findings include;

1. Facility Policy: Emergency Department, Triage, no number, last updated 01/2015, which indicated III. Procedure
A. At the time of triage, the RN will assess each patient, determine and document the level of care needed:
1. I-Life Threatening
2. II- Emergent
3. III- Urgent
4. IV- Less Urgent
5. Non-Urgent
2. Review of the Medical Record of patient #1, on 9/18/2017, at Emergency Department (ED) at facility #2, RN, staff member #20, failed to assign a level of care the patient needed and document it.
3. On 12/13/2017 at1430 hours, ED RN, staff member #20, indicated in interview that she did not document the patient's triage level and that we knew the patient was being sent to facility #1.