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Based on policy review, medical record review and staff interviews, the nursing staff failed to conduct pain assessments for patients in the Emergency Department during triage for 10 of 13 medical records reviewed (Patient #3, 4, 5, 7, 8, 13, 14, 15, 17, and 19) and failed to assess/reassess patient's pain after the administration of medication for 5 of 13 records reviewed. (Patients #5, 7, 12, 13, 23)

Findings included:

Review of the facility's Pain Assessment and Management policy effective date 12/2024 revealed, " ...POLICY This policy provides the guidelines for assessing pain to include the following criteria: 1. Patients will be assessed for the presence, absence, and history of pain using an appropriate rating scale. The pain scale used should be based on the age and condition of the patient and should remain consistent throughout the course of care. the following pain scales are utilized at (Named) Hospital. A. Numeric (0-10): based upon the patient's self-report b. Wong-Baker Faces-used for assessing non-verbal patients or verbal patients that are unable to articulate pain level ...2. Patients will be reassessed for pain after any intervention, and at regular and periodic intervals using the same scale used for assessment ...ASSESSMENT AND REASSESSMENT ...2. All Emergency Department patients ... patients will be assessed for pain with each visit during triage ..."

1.Closed medical record review on 01/08/2025 for Patient #4 revealed a 46-year-old male presented to the Emergency Department (ED) on 08/25/2024 with a chief complaint of ingestions of two cases of alcohol. Review revealed during triage at 1315 vital signs were obtained without documented assessment of pain. Record review revealed Patient #4 left Against Medical Advice with a documented time of 1630 for discharge.

Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients.

Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up.

2.Closed medical record review on 01/08/2025 for Patient #5 revealed a 6-year-old male presented to the Emergency Department on 08/31/2024 with a chief complaint of abdominal pain. Review revealed during triage at 2201 vital signs were obtained without documented assessment of pain. Review revealed 360 milligrams of Tylenol was administered without documentation of pain scale. Patient #5 was documented as discharged on 09/01/2024 at 0141 accompanied by a parent without documentation of response to the administration of the Tylenol.

Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients.

Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up.

3.Closed medical record review on 01/08/2025 for Patient #12 revealed a 59-year-old female presented to the Emergency Department on 10/01/2024 with a chief complaint of fall from bed. Review revealed during triage at 1218 vital signs were obtained with a pain score of 10 out of 10 (with 10 being the most pain). Patient #12 was administered 1 Percocet orally at 1257 for 10 out of 10 pain without reassessment of pain as expected within one hour of the clinical provided intervention. Patient #12 was administered 1 milligram of Hydromorphone intravenously (IV) for a reported pain of 7 out of 10 without documented reassessment .

Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients.

Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up.

4.Closed medical record review on 01/08/2025 for Patient #14 revealed an 83-year-old male presented to the Emergency Department on 11/14/2024 with a chief complaint of abnormal laboratory values. Review revealed during triage at 1330 vital signs were obtained without documented assessment of pain.

Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients.

Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up.

5.Closed medical record review on 01/08/2024 for Patient #17 revealed a 75-year-old male presented to the Emergency Department on 12/18/2024 with a chief complaint of hypotension (low blood pressure). Review revealed during triage at 2035 vital signs were obtained without documented assessment of pain.

Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients.

Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up.

6.Closed medical record review on 01/08/2025 for Patient #19 revealed an 83-year-old female presented to the Emergency Department on 01/01/2025 with a chief complaint of abnormal laboratory values. Review revealed during triage at 1103 vital signs were obtained without documented assessment of pain.

Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients.

Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up.

7.Closed medical record review on 01/09/2025 for Patient #23 revealed a 22-year-old female presented to the Emergency Department on 01/07/2025 with a chief complaint of abdominal pain. Review revealed during triage at 1334 vital signs were obtained with 8 out of 10 documented pain score. Review failed to reveal interventions or follow up provided for the report of pain 8 out of 10.

Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients.

Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up.









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Findings included:

8. Closed medical record review on 01/07/2025 for Patient #3 revealed a 74-year-old male who presented to the Emergency Department (ED) on 08/05/2024 at 1050 with a presenting complaint of abdominal and chest pain. Review revealed during the nursing triage at 1107, vital signs were obtained without a documented assessment of pain. Patient #3 was transferred to Hospital B on 08/05/2024 at 1511 for sepsis-urinary tract infection, elevated troponin level (indicates heart muscle damage), abdominal abscess, concerning for necrotizing fasciitis (flesh-eating disease).

Interview on 01/08/2025 at 1700 with the Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients.

Interview on 01/09/2025 at 1410 with the ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up.

9. Closed medical record review on 01/08/2025 for Patient #7 revealed a 52-year-old female who presented to the ED on 09/23/2024 at 0912 with a chief complaint of stroke-like symptoms. Review revealed during nursing triage at 0944, vital signs were obtained without a documented assessment of pain. Record review revealed Patient #7 received pain medication of Toradol (non-opioid pain management option to alleviate moderate to severe pain) 30 milligrams (mg) intravenous (IV) at 1522 without evidence of a pain assessment or reassessment. Patient #7 was transferred to Hospital B on 09/23/2024 at 1600 for altered mental status.

Interview on 01/08/2025 at 1700 with the Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients.

Interview on 01/09/2025 at 1410 with the ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up.

10. Closed medical record review on 01/08/2025 for Patient #8 revealed a 58-year-old male who presented on 09/23/2024 at 1246 to the ED for shortness of breath. Review revealed during nursing triage at 1328 vital signs were obtained without a documented assessment of pain. Record review revealed Patient #8 was transferred to Hospital C on 09/24/2024 at 0120 for NSTEMI (non-ST elevation myocardial infarction-a type of heart attack).

Interview on 01/08/2025 at 1700 with the Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients.

Interview on 01/09/2025 at 1410 with the ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up.

11. Closed medical record review on 01/09/2025 for Patient #13 revealed a 76-year-old male who presented to the ED on 10/02/2024 at 1950 for neck swelling, and pain into chest. Review revealed during nursing triage at 2001 vital signs were obtained without a documented assessment of pain. Record review revealed Patient #13 was medicated for chest pain at 2025 and 2030 with sublingual (medication given under the tongue) nitroglycerin (medication given to treat/prevent chest pain) without documentation of pain assessment/reassessment. Patient
#13 was transferred to Hospital C on 10/03/2024 at 0350 for STEMI (ST-elevation myocardial infarction-a type of heart attack).

Interview on 01/08/2025 at 1700 with the Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients.

Interview on 01/09/2025 at 1410 with the ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up.

12. Closed medical record review on 01/09/2025 for Patient #15 revealed a 12-year-old female who presented to the ED on 11/15/2024 at 0740 with abdominal pain. Review revealed during nursing triage at 0755 vital signs were obtained without a documented assessment of pain. Patient #15 was transferred to Hospital B on 11/15/2024 at 1320 for abdominal pain, dehydration and hemorrhagic diarrhea.

Interview on 01/08/2025 at 1700 with the Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients.

Interview on 01/09/2025 at 1410 with the ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up.

NC00222402 NC00222027