HospitalInspections.org

Based on medical record review, staff interviews, and review of facility documents, it was determined that the facility failed to ensure: 1.) that pain assessment and reassessment are performed in accordance with facility policy for two of three patient (P) medical records (P2 and P8) reviewed; 2.) that policy and procedures for discharge and disposition of emergency room patients that leave without being seen are implemented and followed for one of two patient medical records (P7).

Findings include:

1. Reference: Facility policy titled, "Assessment/Reassessment" effective date: 4/9/2015 - last reviewed 2/21 stated, " ... 5. All patients are screened for pain management needs upon initial assessment. Patients experiencing acute or chronic pain receive a more comprehensive pain assessment to identify individualized pain control needs. Procedure: ... 3. Reassessments occur at specific timeframes or more often when appropriate ... DEPARTMENT - Nursing Emergency Department - ASSESSMENT - Upon arrival - REASSESSMENT - Every 4 hours and as often as indicated by patient condition ..."

Reference: Facility policy titled, "Pain Assessment and Management" effective date: 6/9/2018 - last reviewed 8/21 stated, " ... Procedure: ... 2. The nurse performs all subsequent pain assessments and reassessments: a) this assessment/reassessment includes pain intensity using an appropriate pain scale, location, onset and other factors indicated. ... 7. Re-assessment of pain is to be completed within 1 hour of an intervention and if pain is not acceptable/tolerable to the patient consider alternative interventions and document in EMR and contact the licensed provider.

1. On 5/25/22 at 11:21 AM, during a review of Patient #2's medical records, it was revealed that P2 arrived at the facility on 4/20/22 at 3:15 AM with complaints of flank pain. At 3:20 AM, the patient had a documented pain level of 10 out of 10. At 5:24 AM, the patient was assessed with a pain level of seven out of 10. Toradol 15 mg IV [intravenous] was administered at 5:30 AM.

There was no evidence of pain reassessment within one hour of an intervention.

2. On 5/25/22 at 1:41 AM, during a review of Patient 8's medical records, the following was revealed:

Review of the ED Triage Note's "Reason for Visit/Problems/Past Medical Hx [history]" section it stated, "Triage Additional Information: states abdominal pain x 2 days and back pain, ... non-labored breathing ...". Under the statement "Pain Present" was the entry "Yes actual or suspected pain".

Review of the Pain Assessment and Reassessment section of P8's medical record indicated that pain was assessed as follows:

On 4/20/22 at 21:30 [9:30], Staff #6, ED RN, documented: Primary Pain Location - Abdomen - Pain Present - Yes actual or suspected pain

On 4/21/22 at 00:46 [12:46 AM], Staff #7, ED RN, documented: Pain Present - Yes actual or suspected pain

On 4/21/22 at 5:30 AM, Staff #7 documented: Pain Present - No actual or suspected pain

Review of the MAR [Medication Administration Record] revealed that the following medications were administered on 4/21/22 at 2:21 AM: Mylanta/Maalox, Pepcid, topical Lidocaine patch (to lower back), Sodium Chloride 0.9% bolus. At 3:52 AM, Ketorolac (Toradol) 15 mg IV push - Primary Pain intensity 10.

There was no documented evidence of a complete pain assessment as indicated in the facility policy.

There was no pain reassessment documented within one hour of an intervention.

This finding was confirmed with Staff #2 and Staff #5 at the time of discovery.


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Reference: Facility document titled, "Discharge Dispositions" states, " ... LWBS (left without being seen): Any patient who leaves prior to receiving a Medical Screening Exam (MSE) will be considered LWBS ...Procedure: LWBS ... If a patient leaves the department prior to a Medical Screening Exam: A minimum of three attempts will be made to locate the patient in the waiting area over a period of one hour. These attempts will be documented in the medical record. Once it is determined the patient has left the department ... the Charge Nurse and/or ANM [assistant nurse manager] is notified and an incident report is completed ..."

On 5/25/22 at 1:41 PM, review of P7's medical record revealed the patient presented to the emergency department (ED) on 4/20/22 at 7:31 PM, with complaints of syncope/collapse.

At 11:45 PM, it was documented that the patient left without being seen. Further review of P7's medical record revealed no documentation of attempts to locate the patient.

At 2:00 PM, during interview, Staff #1 stated, "There is no incident report completed."

The above finding was confirmed with Staff #1 at 2:00 PM.