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Based on interview, and record review, the Hospital failed to have Patient 2 participate in the development of his plan of care for pain and implement their policy and procedure for pain management, when interventions were not performed. This failure had the potential for Patient 2's pain to be unaddressed.

Findings:

Patient 2 presented to the Hospital's Emergency Department (ED) on 6/30/15 with complaints of suicidal ideations (suicidal thoughts), and right hand pain.

Record review of the Hospital's (ED) Record for Patient 2, dated 6/30/15, indicated pain was assessed with vital signs at 8:51 AM. It was rated 4 out of 10 (on a pain scale rating where 1 is mild pain, and 10 is excruciating pain). Vital signs and pain assessment at 10:36 AM indicated a + sign.

In an interview on 7/1/15 at 10:55 AM, the ED Nurse Manager confirmed the + sign indicated the assessment was positive for pain, but a numerical value was not input due to Patient 2's inability or lack of willingness to quantify the pain.

In the same record review, the record stated Patient 2 was the historian for the History of Presenting Illness (HPI-a chronological description of the development of the patient's present illness) portion. The record indicated "HPI...Historian: History provided by patient...ETOH (alcohol) use including ETOH withdrawal who presents with left hand pain and concern for EMS regarding suicidal ideation...He has chronic pain in his left hand, and states that he cannot deal with the pain anymore..." The Review of Systems (ROS- an assessment of different parts and functions of the body) portion indicated "...Musculoskeletal: Historian reports arthalgias (joint pain), joint stiffness..." The Nursing Assessment: Psych/Social portion indicated "...Psych/Social:...Notes: Reports chronic LUE (left upper extremity) to elbow and L (left) hand reports, "I can't deal with this anymore. I just want it to end."..."

The same record review indicated a pain assessment of 10 out of 10 pain with vital signs at 12:20 PM. A set of vital signs were taken at 2:56 PM, with the pain assessment portion left blank. The Disposition portion of the record indicated Patient 2 left the department at 3:39 PM.

In a concurrent interview on 7/1/15 at 10:55 AM, the ED Nurse Manager was asked what interventions were implemented to address Patient 2's pain. The ED Nurse Manager stated the intervention was for Patient 2 to be discharged with a prescription for ibuprofen. It was asked if any non-pharmacological (referring to therapy that does not involve drugs) interventions were performed for Patient 2. The ED Nurse Manager stated there weren't any non-pharmacological notes addressing attempt or completion of interventions.

In the same inteview, the ED Director of Nursing acknowledged that even though pain medications were not given or ordered by the provider, non-pharmacological measures could have been done. The ED Director of Nursing provided the example of repositioning, and held her hands up to demonstrate.

Record review of the Hospital's policy and procedure for Assessment and Management of Pain, review approval date 1/20/15, indicated "...Procedure I. Assessment for Pain...B. 1. When pain is identified through assessment, nursing will implement non-pharmacological interventions as appropriate...III. Interventions Pain management interventions will be implemented within 2 hours, and may include, but are not limited to: Non- Pharmacological Interventions..."

Based on interview and record review, the facility failed to ensure verbal order was signed by the physician within 48 hours, for one of 30 sampled patient (Patient 30). This had the potential for physician's orders not to be transcribed and noted correctly which could jeopardize the patient health and safety of the patient.

Findings:

Patient 30 was admitted to the facility on 5/19/15 for spinal abscess and had multiple surgeries to drain the abscess. On 6/2/15, he went for "Irrigation of Back Wound - upper and lower back."

During medical record review of Patient 30 on 7/1/15, the verbal order indicated, "Mineral oil x (times) 4 for topical use on back, Epinephrine (used to constrict blood vessels to numb pain) 1:1000 1 ml (milliliters) for topical use on back, Bacitracin zinc (topical antibiotic) ointment for topical back application." The verbal order was dated 6/4/15 at 11:15 AM, which was signed by a Registered Nurse (RN) at PACU (Post Anesthesia Care Unit).

During an interview on 7/1/15 at 10:30 AM, RN 1 stated any Registered Nurses should ask the physician to sign the order if it was noted to have not been signed.

Review of the facility's Transcription of Physician's Orders policy and procedure, revised 6/13, indicated, "All orders are checked every shift by a licensed staff (RN, LVN (Licensed Vocational Nurse, LPT (Licensed Psychiatric Technician) to ensure that every order has been transcribed completely and accurately to the appropriate form or entered into the computer. Chart check is initiated at the end of each shift, by the primary licensed nurse, to ensure accuracy and completeness of physician order transcription... Verbal and Telephone Orders...C. In all other areas, verbal and telephone orders are only accepted in emergent situations, for pain management or situations in which delay may adversely affect the patient. The prescriber or furnisher must countersign these orders within 48 hours."