HospitalInspections.org

Based on review of facility documentation, medical record review (MR), and employee interview (EMP), it was determined that the facility failed to complete pain evaluations to avoid personal discomfort of the patient for one of ten medical records. (MR1).

Findings include:

Review, at approximately at 11:00 AM on September 15, 2017, of the facility policy, "Pain Management" effective June 3, 2016, revealed "... I. POLICY It is the policy of UPMC to provide excellence in patient care throughout the life span. The relief of pain is inherent in patient care and includes relief of physical and psychosocial symptoms associated with pain. Pain management is a vital part of patient care and all patients have a right to pain relief. ... PURPOSE ... On initial evaluation and at regular intervals, assess for the presence, quality and intensity of pain and use patients' self report as the primary indicator of pain. ..."

1. Review of MR1 on September 13, 2017, at approximately 1:00 PM revealed that the patient was admitted to the hospital on August 24, 2017, and was discharged on November 11, 2017.

2. Continued review of MR1 on September 13, 2017, at approximately 2:00 PM revealed that pain assessments were not completed on October 25, 2017, - October 27, 2017, and on November 11, 2017.

3. During an interview on September 14, 2017, EMP1 confirmed that above.