HospitalInspections.org

Based on review of facility policies, review of security video, an Emergency Medical Services (EMS) Run Report, medical record review and interview, the facility failed to ensure the exercise of patient's rights requirements were met for 1 patient (#1) who was held in the EMS holding area of the facility of 3 patients reviewed.

The findings include:

Review of the facility policy, "Pain Management," revised 3/2024, revealed "...The relief of pain and suffering is integral to the mission of the [name of hospital]. Each patient has the right to appropriate assessment and management of pain. [name of hospital] has made the relief of pain a priority for the institution and is committed to ensure that adequate pain management is provided to patients...Management of pain is based on appropriate pain assessment, which includes an understanding that pain is individualized and is a subjective experience. Therefore, the patient is usually the best judge of the intensity of pain and effectiveness of pain relief..."

Review of the facility, "Patient Guide: Your Hospital Rights and Responsibilities," not dated revealed "You have the right to an appropriate pain assessment and management..."

Review of the Emergency Medical Service (EMS) Run Report dated 8/25/2025 at 3:31 PM, revealed EMS responded to Patient #1, 57-year-old-female who fell at home and suffered a fracture of her right humerus (upper arm). Patient #1"...described her arm as backwards..." Patient #1 complained of severe pain in her upper right arm and reported a pain level of "...above 10..." Patient #1's blood pressure was 154/70. Further review of the EMS Run Report indicated a possible complete rotation of her arm from her body. A report of the patient's condition was called by the EMS Paramedic to the ED with a trauma alert. Intravenous (IV) pain medication was administered four times during transport to the hospital for pain control.

Review of the Security Video Recording on 8/25/2025 at 6:29 PM, revealed the Emergency Medical Services (EMS) transporting Patient #1 into the facility on a stretcher into the EMS holding area. The EMS Paramedic was visualized going to the Medic Desk at 6:33 PM. The Trauma Nurse was visualized standing by Patient #1's stretcher in the EMS holding area at 6:38 PM. The EMS Paramedic was seen leaving the ED (emergency department) holding area's double doors. A Hospital Paramedic was visualized administering medication to Patient #1 at 7:40 PM. The patient was transported from the ED holding area at 8:03 PM by EMS enroute to an ED Room.

Medical record review of the ED record dated 8/25/2025 at 7:44 PM, revealed Morphine Sulfate 2 milligrams (mg) (a unit of metric measurement equal to one-thousandth of a gram) was ordered by Physician #1 and was administered IV for pain while the patient was in the EMS holding area. Review revealed Patient #1 had waited one hour and eleven minutes before pain medication was administered for a complex humerus fracture.

Record review of the ED x-ray report revealed a comminuted (bone is broken into multiple small pieces) and Angulated (bone fragments are displaced at an angle to each other) Fracture of the Proximal (closest) to Mid Humerus (the long bone in the upper arm) with Large Butterfly (when two fracture lines meet to form a triangle) Fragment.

Record review revealed no pain assessment was performed by the Facility ED Staff prior to the EMS Paramedic asking ED staff for pain medication for Patient #1. A pain score of 10 was documented in the Medication Administration Record (MAR) after ED staff administered the pain medication.

Record review dated 8/25/2025 at 8:06 PM, by RN A revealed Patient #1 was moved from the EMS holding area to an ED room after waiting for 1 hour and 34 minutes. Patient #1's vital signs were taken after the patient was moved to an ED room; temperature was 97.5 degrees Fahrenheit, Pulse 69, Respirations 21, Blood Pressure 210/87, and the Pulse Oxygen was 99% and the patient's pain level was documented as 10, representing severe pain.

During an interview on 9/12/2025 at 1:48 PM, with the Emergency Department Medical Director revealed there is a surge staffing plan. He stated technically EMS staff cannot give anything for pain in the ED. The ED Medical Director stated there was probably a staffing challenge that day and it looked like the surge plan failed.

During an interview on 9/12/2025 at 2:07 PM, with the ED Nurse Manager revealed on 8/25/2025 the ED Team Leader was also the RN in charge at the Medic Desk. The Nurse Manager explained on 8/25/2025 there was 105 patients in the ED at one time. She stated the average time spent by EMS in the holding area with their patients is 21.9 minutes. When the Nurse Manager was asked why the patient did not receive pain medication for greater than an hour after arriving in the ED, the Nurse Manager stated the patient had 300 mcg. of Fentanyl in the ambulance enroute to the ED.

During an interview on 9/15/2025 at 9:51 AM, the Trauma Nurse revealed on 8/25/2025 all the trauma bays were full and the Main ED was full. The Trauma Nurse revealed the patient was in a type of blow-up full body immobilizer. He stated this splint was challenging. She had a long bone fracture and he stated the patient was in a lot of pain. He evaluated her for trauma but ".... there wasn't anything they could do..." He confirmed "...he did not document his assessment..."

During a telephone interview on 9/15/25 at 11:21 AM, Physician #2 revealed the patient had an odd fracture pattern with a Butterfly fracture, "...Her bone had broken into three pieces." He stated the fracture was not a simple reduction, it was displaced. Physician #2 stated the humerus fracture "...caused a lot of pain..."

During a telephone interview on 9/15/2025 at 11:45 AM, Physician #1 revealed he was the lead physician in Trauma Bay the evening Patient #1 came to the ED. He stated he was approached by the EMS Paramedic who asked for pain medication for the patient. He gave the order for pain medication while the patient was in the ED holding area.

During a telephone interview on 9/15/2025 at 4:03 PM, RN A revealed she helped transfer the patient from the EMS stretcher to an ED stretcher in the Main ED and stated "the patient told us she was in a lot of pain."

During a telephone interview on 9/15/2025 at 4:14 PM, RN B stated "...You didn't need an x-ray to tell her arm was broken. She had the kind of break that can only be fixed in surgery to take the pain away..."

During a telephone interview on 9/16/2025 at 8:55 PM, the EMS Advanced Emergency Medical Technician (AEMT) revealed he was in the ED holding area with the patient on 8/25/2025. He stated Patient #1 was given pain medication in the ambulance, but it had worn off while they were waiting in the ED holding area. He stated the patient began to cry out loudly in pain, and was moaning. The EMS AEMT stated the EMS Paramedic left multiple times and went to the Medic Desk and into the Main ED to get help for Patient #1.