HospitalInspections.org

Based on interviews and documents reviewed, the facility failed to ensure staff assessed and addressed patient pain levels according to facility policy in three of five obstetrical emergency department (OBED) patients reviewed. (Patients #1, #2, and #4)

Findings include:

Facility policy:

The Pain Management policy read, pain was assessed upon admission, during and after any known pain-producing event, with each new report of pain and at least once a shift. Pain reassessment was done within two hours of pain interventions.

1. The facility failed to ensure staff assessed and addressed patient pain levels according to facility policy.

a. A review of Patient #1's medical record revealed Patient #1 delivered a baby on 12/22/24 at 2:30 a.m. at a community birth center and experienced a second degree perineal tear (a tear that extends through the muscles and skin of the perineum, the area between the vagina and anus). Patient #1 arrived by ambulance at the facility at 4:02 a.m. for delivery of a retained placenta (the placenta did not separate from the uterine wall following childbirth). The medical record revealed medical provider (MD) #1 performed a vaginal exam and evacuated 500 mL of clotted blood. The review revealed no evidence of a pain assessment performed or pain medication offered prior to the vaginal exam.

The medical record also revealed staff followed the vaginal exam with an initial pain assessment at 4:20 a.m., which revealed Patient #1 had a 10/10 level of pain. Further review of Patient #1's medical record revealed staff administered 100 mcg of fentanyl (a narcotic pain medication) at 4:21 a.m. MD #1 then performed a bimanual massage uterine sweep exam (a procedure done with the provider's first hand inside the vagina and uterus while they put their second hand on the abdomen to push on the uterus). The medical record revealed staff medicated Patient #1 with 600 mg of ibuprofen (an anti-inflammatory pain medication) at 6:08 a.m. There was no evidence of a pain assessment performed after the administration of fentanyl, during or after the bimanual massage uterine sweep, or before the administration of ibuprofen. The review revealed staff performed the next pain assessment at 7:52 a.m., more than three hours after the pain producing event. Patient #1 left the facility against medical advice (AMA) at 9:35 a.m.

This was in contrast to the Pain Management policy, which read, pain was assessed upon admission, during and after any known pain-producing event, and pain reassessment was done within two hours of pain interventions.

b. A review of Patient #2's medical record revealed Patient #2 arrived at the OBED on 3/10/25 at 8:15 p.m. after they experienced a mechanical fall while 38 weeks pregnant. The medical record revealed Patient #2 was discharged home at 9:53 p.m., with instructions to follow up with their doctor on 3/13/25, take acetaminophen (a pain medication) as needed, and apply a lidocaine adhesive patch (a topical pain reliever) every morning. The medical record revealed the medical provider had discussed Patient #2's pain, however, staff did not perform a pain assessment or provide pain-relieving interventions to Patient #2 during their stay.

c. A review of Patient #4's medical record revealed Patient #4 was 33 weeks pregnant and arrived at the OBED on 9/14/25 at 10:44 p.m. with abdominal and back pain. The medical record revealed Patient #4 had a kidney stone and a urinary tract infection (UTI). Provider documentation revealed Patient #4 was instructed to take acetaminophen for pain. Patient #4 was discharged at 5:11 a.m. There was no evidence of a pain assessment or pain-relieving interventions provided to Patient #4 during their stay. Additionally, acetaminophen instructions were not included on Patient #4's discharge instructions.

The medical record reviews for Patients #2 and #4 were in contrast to the Pain Management policy, which read, pain was assessed upon admission, and during and after any known pain-producing event.

d. Between 9/29/25 and 10/1/25, interviews conducted with staff revealed the following:

i. In an interview with registered nurse (RN) #2, RN #2 stated a manual sweep for a retained placenta was uncomfortable and staff assessed for pain and administered fentanyl for patients in pain. RN #2 reviewed Patient #1's monitoring strip from the medical record and stated Patient #1 was in pain on 12/22/24 at 4:17 a.m., as evidenced by an increase in Patient #1's heart rate, which started at 80 beats/minute and went above 120 beats/minute.

ii. In an interview with RN #4, RN #4 stated staff assessed pain upon arrival. RN #4 stated additional assessments were completed if the patient's condition changed, or if the patient had pain producing procedures performed. RN #4 stated they reassessed patients within two hours of a pain management intervention per the facility's pain management policy. RN #4 stated when staff did not manage patients' pain, it caused additional trauma for the patient.

iii. In an interview with MD #3, MD #3 stated they offered patients fentanyl for pain control for procedures related to retained placentas. MD #3 stated fentanyl took effect within a minute or two, and unless the patient hemorrhaged, they took the time to medicate patients for their comfort. MD #3 stated they wanted patients comfortable to support cooperation with the procedure, and to prevent unnecessary mental or emotional trauma from the experience.

iv. In an interview with MD #1, MD #1 stated Patient #1's placenta had started to release from the uterus and MD #1 continued to massage the uterus externally on Patient #1's abdomen. MD #1 stated Patient #1 became uncomfortable, so they stopped the massage, administered fentanyl, and then resumed the bimanual sweep procedure. MD #1 stated they offered Patient #1 pain medication prior to the first vaginal exam, however, Patient #1 declined. MD #1 stated Patient #1 realized they needed pain medication for the procedure once MD #1 started the examination, so staff administered the fentanyl.

This was in contrast to Patient #1's medical record review, which revealed no evidence that staff assessed Patient #1's pain, offered, or administered pain medication prior to the first vaginal exam according to facility policy.