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Tag No.: A0395
Based on medical record review, staff interview, and policy review, the hospital failed to ensure the patient's pain level was reassessed one hour following pain medication administration for four of twenty medical records reviewed (Patient's #6, #13, #14, # 20). The active census was 117.
Findings include:
Review of the Policy and Procedure for Management of Pain ID: 2015558 (Revised 01/16) revealed clinicians were to reassess patients' pain level with routine assessments and one hour following interventions whether medication or non-pharmacologic interventions.
1. Review of the medical record for Patient #6 was conducted on 11/22/16 and 11/23/16. Patient #6 presented to the emergency department on 06/01/16 at 4:33 PM with a chief complaint of right lower quadrant pain and 19 weeks pregnant. Patient #6 was assessed for pain at a level nine on a one to ten pain scale, and the patient was given Tylenol 1000 milligrams (mg) on 06/01/16 at 5:39 PM. Patient #6 was discharged on 06/01/16 at 10:53 PM, but there was no documentation the patient was reassessed for pain upon discharge or after the Tylenol was given.
An interview with Staff I on 11/23/16 at 11:05 AM confirmed the findings.
2. Review of Patient #13's medical record revealed the patient arrived to the emergency room on 07/05/16 complaining of abdominal pain of a three on a pain scale from one to ten. At 6:05 PM, the patient was given Tylenol 1000 mg for pain. The patient was discharged from the emergency room on 07/05/16 at 6:08 PM without a pain reassessment.
3. Review of Patient #14's medical record revealed the patient arrived to the emergency room on 07/07/16 complaining of a headache rated at a three on a pain scale from one to ten. At 10:32 AM the patient was given Tylenol 650 mg for pain. The patient was discharged from the emergency room on 07/07/16 at 12:08 PM. There was no evidence the patient was reassessed for pain after the Tylenol was given.
Interview on 11/23/16 at approximately 10:50 AM Staff I verified that Patient #13 and Patient #14 were not reassessed for pain after being given Tylenol for pain.
4. Review of the medical record for Patient #20 revealed the patient presented to the emergency department on 06/23/16 at 10:09 PM with a chief complaint of of left rib/chest pain following a fall. Physician and nursing documentation confirmed the patient's chief complaint to be left rib pain with the location of injury being the chest area. Chest/rib pain was described as being severe, sharp and aching, and rated ten out of ten on a pain scale of one to ten during triage.
Physician's orders included Nubain (pain medication) 10 mg intramuscularly once. The registered nurse administered the injection at 10:32 PM and failed to reassess and/or document pain one hour later per facility policy.
This finding was confirmed with Staff E on 11/22/16 at 2:43 PM.