HospitalInspections.org

Based on observation, record Review and interview the facility failed to document pre and post procedure pain assessments for 7 (Patient #4, #5, #7, #8, #9, #10 and #11) Patients out of 11 Patient medical records reviewed.

Findings:

Review of Facility Policy effective date of 08/03/2022, titled, "Procedures - Patient Preparation and Assessment for Procedures," revealed, "Assessing and relieving pain is the responsibility of all healthcare professionals (HCPs) caring for children. Procedures are to be considered biopsychosocial experiences for the child rather that simply tasks to be completed by a health care professional...effective comfort management during procedures depends on collaboration and planning between the child, the family , and various members of the health care team...Ambulatory: A plan must be in place for managing patient distress and comfort if the procedure is likely to produce pain and or anxiety....Patient will be screened for pain prior to and after procedure. If the patient's pain or anxiety is not well controlled during the procedure, the procedure should be temporarily stopped (if safe) while the process is evaluated and the patient is given additional support (pharmacologic and/or non-pharmacologic)...Screen for Pain: Ambulatory:...RN (Registered Nurse) will screen for pain prior to the procedure...During the procedure:....Evaluate tolerance/acceptability of procedure: Pause if the patient is not tolerating the procedure well--HCPs are expected to stop/pause the procedure (as appropriate) in order to advocate for the patient....signs the things may not be going as well as possible...needing to restrain the child as opposed to supporting the child,..a crying child...After the Procedure: Screen for pain following the procedure and document result....if pain screen is positive, perform a pain assessment and provide interventions as appropriate...if the patient is unable to tolerate procedure without significant distress or there is concern for their safety, it may be appropriate to defer the procedure or adjust the level of sedation."

Review of Facility Policy effective date of 07/13/2022, titled, "Assessment, Reassessment, Documentation of a Patient," revealed, "Patient care staff performs assessments and completes documentation for all patients who receive care and treatment...Information is documented as soon as possible after assessment/intervention/evaluation of the patient...Patient Assessment and Required Documentation: Intial data will be gathered at the point of entry into the [Facility] system...The purpose of completing the initial assessment is to....identify the patient's immediate and emerging needs relative to physiological status including pain...Determine the care the patient requires."

On 11/13/2024 from 8:00 AM -10:20 AM during Medical Record Review with Imaging Manager E, pre or post procedure pain assessments were not completed for Pt's #4, #5, #7, #8, #9, and #10 who had all received G/J (Gastrostomy/Jejunostomy) (tube placed in the stomach or intestines) tube replacements and no pre or post procedure pain assessment was completed for Pt. #11 who had received bilateral knee injections for rheumatoid arthritis.

In an interview on 11/13/2024 at 1:27 PM Manager E stated, "No pain was assessed and it should have been. Our normal practice is to do a pain assessment with a set of vitals."