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Based on policy review, document review, medical record review and interview, the hospital failed to ensure nursing services administered pain medications timely in the Emergency Department (ED) for a patient that complained of pain upon arrival.

The findings included:

1. The hospital nursing services failed to ensure pain medication was administered timely for a patient who complained of pain in the ED.

Refer to A-0395

Based on hospital policy and procedure, medical record review, and interview, the Hospital failed to ensure a patient in the Emergency Department (ED) received pain medication timely after complaints of pain were verbalized for 1 of 2 (Patient #2) sample patients who were seen in the ED.

The findings included:

1. Review of the hospital policy Pain Assessment and Reassessment, Management and Documentation revealed, "...Reassessment of pain is conducted with each shift assessment and after the administration of pain medication...Pain reassessment after the administration of pain medication is dependent on several patient factors (age and disease process) and medication factors (drug, dose, route, absorption, onset, peak, etc). These factors should be considered when planning the timing of post-pain medication assessment...[Named Hospital] treats the patient's pain...Pain Management (includes the following)...Identify the location of the pain and whether it is acute or chronic...Administer the prescribed analgesic...Pain Assessment (includes the following) Ask patient if he or she is in pain...Examine site of patient's pain when possible. Inspect for discoloration, swelling...Palpate area for change in temperature, altered sensation and tenderness...[Named Hospital] uses...scales to assess pain. All pain scales range from 1 to 10 [1= least pain, 10= most severe pain]..."

2. Medical record review revealed Patient #2 was admitted to the Emergency Department on 1/3/2021 at 5:26 PM with complaints of multiple falls, pain and had diagnoses to include Cancer, with Brain and Bone Metastases (Cancer cells spread to the brain and bones).

Review of the Emergency Patient Record dated 1/3/2021 revealed Patient #2 arrived at the Emergency Department (ED) at 5:27 PM and the Triage began at 5:29 PM. The Rapid Initial Assessment revealed, "...Subjective assessment: HAS HAD CHRONIC NECK PAIN FOR SEVERAL MONTHS WITH A HISTORY OF CANCER WITH BONE METS [Metastasis: Cancer cells spread to the bones] HAS FALLEN SEVERAL TIMES RECENTLY THE PAIN IS NO WORSE THAN PRIOR...DOES STATE THAT HE FEELS LIKE HE IS HAVING SOME PAIN IN THE BASE OF HIS LUNGS NOT RELATED TO THE FALL...Objective assessment...Onset of Symptoms Date: 01/03/21...Pain intensity: 5 [pain scale of 0-10 with 0 = no pain, 10= most severe pain]...Chief Complaint: Neck Pain...Moderate pain-5...PAIN ASSESSMENT & REASSESSMT...01/03/21...1847[6:47 PM]...Pain intensity: 6...Moderate pain..."

Review of the History of Present Illness dated 1/3/2021 at 5:55 PM revealed Patient #1's chief complaint was a fall and generalized weakness and reports extremity pain.

Review of the Radiological Report Exam dated 1/3/2021 at 10:40 PM revealed, "...FOREARM RIGHT...FINDINGS/IMPRESSION...There is mild diffuse nonspecific subcutaneous soft tissue swelling/edema about the visualized forearm, correlate clinically...HAND RIGHT...There is some mild osteoarthritis present..."

Review of the Discharge Report Audit Events revealed the right forearm and the right hand x-rays were completed by Radiology on 1/3/2021 at 11:10 PM and 11:18 PM respectively. The ordering Physician signed the Radiology reports electronically on 1/4/2021 at 3:19 AM.

Review of the History of Present Illness dated 1/4/2021 at 1:36 AM revealed,
"...Also patient's x-ray showed no fracture or dislocation patient is complaining of excruciating right wrist pain...Problem List...Fall...PRN pain medications..."

Review of the Medication Discharge Summary revealed Percocet 5mg/325mg (a combination of oxycodone [a narcotic medication] 5 mg and acetaminophen [a non narcotic medication] 325 mg) was ordered on 1/4/2021 at 1:49 AM for 1 tablet every 4 hours as needed for moderate pain 4-6.
Percocet was administered at 3:14 AM (1 hour and 24 minutes after the order was entered by the physician). Patient #2's pain level at the time of administration was 6.

Review of the Emergency Patient Record dated 1/4/2021 at 5:37 AM revealed, "...NECK PAIN INJURY REASSESSMENT...No change...PAIN ASSESSMENT...Pain intensity: 3...Mild pain..."

There was no documentation to confirm Patient #2's wrist pain was reassessed following the administration of pain medication on 1/4/2021 at 3:14 AM.

Review of the Medication Discharge Summary revealed Percocet 5 mg/325 mg was ordered on 1/4/2021 at 9:35 AM for 1 tablet every 4 hours as needed for moderate pain 4-6. Patient #2's pain level at the time of administration was 5. Patient #2's pain was reassessed at 2:09 PM (4 hours and 35 minutes later) with a level of 4 (moderate pain).
There was no documentation of any additional reassessments or interventions for the continued pain.

Review of the Physical Therapy Evaluation dated 1/4/2021 at 11:52 AM revealed, "...SUBJECTIVE...Pain location: R. [Right] HAND...NOTED INC [increased] SWELLING AND REDNESS TO R HAND DURING ACTIVITIES..."

Review of the Occupational Therapy Evaluation dated 1/4/2021 at 11:54 AM revealed, "...ROM [Range of Motion] Comment: PT [Patient] R HAND FROM WRIST DOWN WAS VERY SWOLLEN + TENDER TO TOUCH..."

Review of a Physician Clinical Note dated 1/4/2021 at 5:41 PM revealed, "...He does have some mild swelling in his right upper extremity, and is clear that he is trying not to use his right hand due to his pain. Will add on some analgesia..."

During an interview with the Vice President of Quality and Risk Management on 5/19/2021 at 3:19 PM revealed Patient #2 had fallen at home. Patient #1 was in chronic pain in the Emergency Department. The Vice President of Quality and Risk Management stated, "...We don't always give pain medication for chronic pain. We don't always treat it pharmacologically. We also use positions, darken the room, reduce the noise level etc. as interventions for chronic pain. As soon as [Patient #1] complained of wrist pain, which was acute, pain medications were ordered."

Patient #2 was in the ED from 5:29 PM on 1/3/2021 until 3:14 PM on 1/4/2021 for a total of 9 hours and 45 minutes before pain medication was administered. The hospital staff were aware of Patient #2's complaints of pain at the time of arrival in the ED. There was no documenation of non-pharmacological interventions implemented prior to the administration of Percocet.