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MEDSTAR GEORGETOWN UNIVERSITY HOSPITAL
CONTENT OF RECORD
Tag No.: A0449
Based on medical record review, policy review and staff confirmation facility staff failed to document pain assessments in three (3) of 22 reviewed records.
The findings include:
The MedStar Georgetown University Hospital Policy # 60, Issued: August 27, 2002 and last revised November 22, 2016, titled: Pain Assessment states "it is the policy of MedStar Georgetown University Hospital that all inpatients and outpatients are assessed for pain according to the MedStar Georgetown University Hospital Pain Management Guidelines". The policy defines pain scale, 'the hospital uses methods to assess pain that is consistent with the patient's age, condition and ability to understand. The standard scales used to assess pain are the ...0-10 numeric scale with 10 being high ..."
The MedStar Georgetown University Division of Nursing Clinical Standard Policy, Issued: October 2014 and Revised: May 2015 titled: Assessment of Pain in the Adult Patient, Standards of Care under section Reassessment/Evaluation states "(b) reassess pain 60 minutes after oral pain medication administration."
A. The Emergency Department (ED) staff evaluated Patient# 1 for left shoulder pain.
On May 21, 2017, at 15:22 the medication administration record (MAR) reveals Acetaminophen (Tylenol) 650 mg two (2) tablets PO (by mouth) one time, (indication: other pain/ headache) as administered to the patient.
On July, 14, 2017 at approximately 11:00 AM, a review of the MAR dated May 21, 2017, under the Pain Assessment section there was a recorded numeric pain score of seven (7). The Pain Description section reveals pain location: shoulder, pain laterality: left; pain quality: aching.
Upon further review, the medication administration record lacked documented evidence that nursing staff recorded a reassessment (numeric pain score) of the patient's response to the intervention (treatment).
B. The Emergency Department (ED) staff evaluated Patient#10 for right arm pain.
On May 2, 2017 at 9:49 AM the medication administration record (MAR) reveals Ibuprofen 800 mg=2 tabs, PO (by mouth) one time indication: Pain STAT (at once) as being administered to the patient.
On May 2, 2017 at approximately at 9:49 AM the medication administration record (MAR) reveals Ibuprofen 800 mg two (2) tablets PO (by mouth) one time indication: Pain STAT (at once) as administered to the patient.
On July, 14, 2017 at approximately 11:00 AM, a review of the medication administration record (MAR) dated May 21, 2017, under the Pain Assessment section there was a recorded numeric pain score of 10. The Pain Description section reveals pain location: arm upper, pain laterality: right; pain quality: sharp.
Upon further review, the medication administration record lacked documented evidence that nursing staff recorded a reassessment (numeric pain score) of the patient's response to the intervention (treatment).
C. The Emergency Department (ED) staff evaluated Patient#12 for left foot pain.
On July, 14, 2017 at approximately 11:00 AM, a review of Patient# 12 medical record dated February 3, 2017, under the Pain Assessment [Pain Present] section reveals "Yes, actual or suspected pain". The Pain Description section was left blank.
Upon further review, the Pain Assessment section of the medical chart lacked evidence that nursing staff assessed and or recorded the patient's pain level.
The surveyor conducted a face-to-face interview with Employee# 3 and Employee #6 on July 15, 2017, at approximately 2:00 PM who acknowledged the findings.